The New Sydenham Society - Forgotten Books

BIENNIAL RETROSPECT

M E D I C I N E,S U R G E R Y

,

AND THE IR

ALL IED SC IE NCE S,

1 8 7 1 - 7 2 .

EDITED BY

MR. H. POWE R,DR . SHE PHERD,

MR. WAREN TAY ,

MR . R . B. CAR TER DR . PHILLIPS,

DR . T . STEVENSON,

THE NEW SYDENHAM SOCIETY .

L O N D O N .

MDCCCLXXIII.

ADLARD, BARTHOLOMEW CLOSE .

C ON T E N T S.

I.—REPORT ON PHY SIOLOGY .

By HENRY POWER, M .E . Lond .

II.-REPORT ON PRACTICAL MEDICINE .

By A. B . SHEPHERD, M.A M.E .,

III.—REPORT ON SURGERY .

By WAREN TAY ,

IV .—REPORT ON OPHTHALMIC MEDICINE AND

SURGERY .

By ROBERT BRUDENE LL CARTER;

V.—REPORT ON MIDWIFERY AND THE DISEASES OF

WOMEN AND CHILDREN.

By J. J. PHILLIPS, M.D. Lond.

VL REPORT ON MEDICAL JURISPRUDENCE .

By THOMAS STEVENSON, M.D. Lond.,433

CONTENTS.

VIL—REPORT ON MATERIA MEDICA AND GENERAL

THERAPEUTICS .

By THOMAS STE VENSON, M.D. Lond.,

VIII.—REPORT ON PUBLIC HEALTH.

By THOMAS STEVENSON , M .D. Lond.,

INDEX

R E P O R T

ON THE

PROGRESS OF PHY SIOLOGY AND THE

ALLIED SCIENCES,

DURING THE Y EARS 187 1 AND 1872 .

HENRY POWER,

M .E . LOND . ,

EXAMINER IN PHY SIOLOGY AND COMPARAT IV E ANAT OMY IN THE UN IV ERSITY OF

LONDON ; SENIOR OPHTHALM IC SURGE ON T O ST . BAR THOLOMEW’

S

HOSPITAL.

THE principal treatise on phys io lo gy that has b een pub lished duringthe las t two years in the E nglish language is the fourth vo lume o f Dr .

Flint’s Phys io logy o f Man ,

’ which emb rac es the c ons ideration o f the

nervous system,and is o ne o f the best, as it is the m o st c omplete, ex

po s itions o f the state o f our knowledge o f nerve phys io logy that weat present po ssess .

Dr. Bennett adds one more student’ s manual to tho se already exi sting,which

,bes ides the info rm ation usually given in such text-bo oks

, c on

tains three chapters o r section s devo ted to practical chemical phys io logy,to practical histo logical physio logy, and to practic al experimental physio logy. T he first o f these has been written by Dr. McKendrick

,and

will probably pro ve o f much service to students .

Dr. Nicho ls has published a manual o f phys io logy applied to so c ialand sanitary science, which , with some erro rs and ec centric ities, c ontainsmuch thoughtful writing.

Dr. Dalton has issued a fifth edition o f his Human Physio logy,’ thesections in which on the liver and on repro duction are bo th o riginaland excellent .Dr. Rutherfo rd has done important service by publishing a series o flec tures in the Lancet ’ fo r 187 1

-

7 2 on experimenta l phys io logy, inwhich the princ ipal facts , and the evidence suppo rting tho se facts, thathave been made o ut during the last few years upon the functions and

vital pro perties o f musc le, nerve, and gland, are given with great c learnes s and much o riginality .

The Sydenham So c iety has published a translatio n o f the s econdvo lume o f Stricker’ s Manual o fHisto logy,’ and also the first vo lum e

o f Rindfleisch’

s Patho logical Hi sto logy .

’

France has produced but little. The n inth vo lume o f Milne

2 REPORT ON PHY SIOLOGY .

E dwards’s large wo rk on Comparative Phys io lo gy,

’ which is o c cupiedwith the tegumentary appendages o f animals , has appeared ; C laude

Bernard has published a series o f lectures o n E xperimental Phys iology, ” delivered at the Co llege de France , and an excellent c ourse o f

fo rty lectures o n Animal Heat, ” by the s ame autho r, 1s c ontamed In

the Revue Scientifique .

’

Germany, as usual , has b een very active, her ac tl vity exhibiting itselfin the produc tion o fa mul titude o fpapers rather than o f c omplete wo rk s ;s o me o f these , however, atta in ing almo st the size o f a treatise (witnes sthe essay o f Schm idt on Fibrin ,

”in Pfiiiger

’

s These are

published in innumerable j ournals , rendering it difficul t to o btain so me,

s till more difiicult to find the time to run has tily thro ugh all , and almo s timpo ss ible to analyse them in such a manner a s to do jus tice to the

valuable wo rk and results they frequently c o ntain . The mere reco rd

o f them wo uld o c cupy the entire space allowed fo r this no tice o f

physio logical progress .An interesting lecture on

“ Dust and Smoke was delivered b y

Prof. Tyndall, at the Royal Institutio n, o n June 9, 187 1 , c onta iningstatements and detailing experiments , which have since been frequentlyreferred to , as showing the presence o f much flo ating o rganic matter ino rdinary air, and as supporting the germ theo ry .

Bastian* c ontributes a ver impo rtant wo rk o n the mode o f o rigin o f

the s implest fo rms o f an imal ife, such as Bac teria, T o rulw,andVibrio s .

These he believes he has demons trated c an develo p witho ut antec edentspo res in o rganic infus io n s , and even in so lutions o f ammo niacal salts

,

which have been expo sed to temperatures suppo sed to be suffic ient todestroy all life. Such develo pment he terms archebios is . He alsomaintains that by a pro ces s o f hetero genesis the higher fo rm s o f ciliatedinfuso ria , and even a Ro tifer, may develo p from the pro ligero us pellic leo f o rganic so lutions .Dr. Sanders on? c o rro bo rates Dr. Bastian ’

s statements in vario usparticulars , and has s atisfied him self that

,fo llowing Dr. Bas tian ’

s

direc tions , infus ions can be prepared which are no t deprived by an

ebullition o f from five to ten m inutes o f the facul ty o f undergo ing tho sechem ical changes which are characterised by the presence o f swarms o f

Bacteria, and that the develo pment o f these o rgan isms can pro ceedwiththe greatest ac tivity in hermetically sea led '

glas s ves sels , from whichalmo st the who le o f the air has been expelled by bo iling.

Crace Calverti c ontends , in Oppo sition to Dr. Bas tian,that when

living bodies appear in any so lutio n they pro ceed from the develo pment o f germ s introduced from witho ut o r previo usly present and no t

killed.

by.

the temperature to which they have been expo sed. He findsthat life 1s retained by some o f the lower fo rms o f an imal life even afterexpo sure to a temperature o f 300

0F . , but no t o f It may jus t be

n o tic ed that Dr . Blake§ has found c erta in diatoms growing In abnudance In water at a tem perature o f 163

° Fahr.

The Beginn ings of Life,’ London, Macm illan, 2 vo ls , pp . 475 and 640 , 187 2 .

1‘ ‘Nature,

’

Dec . 14 , 2 0 , 2 7, 1872 .

I Pro ceed. Roy. So c xix, 409, 187 1 .

‘Month . Mic . 1873, 7 1 .

ABSORPTION . 3

Johnsonfi“ speaking o f the transmutation o f fo rm in certainPro to zo a , o bs erves that if an examinatio n be made o f s ome o f the green

growths on m o ist surfaces we shall find one c om po sed o f a dust , towhich the name o f Chlo ro c o c cus has been applied ; ano ther, a green

s c um o n the surface o f a liquid, which has received the name o f E uglenaa third, fo rming patches o f dark green s lime

,is called O sc illato ria ; a

fourth, Lingbya ; a fifth, Vaucheria ; and a sixth,Schizo nema . Mo re

detailed exam inatio n o f these separately named pro duc ts , and a studyo f their life histo ry, leads to the o pinion that they are all stages o f de

velopment o f s ome one c ommon so urce,which he believes to be the

Monad. He has him self watched and here depic ts the tran sfo rm ationo f Paramaec ium into Vorticella , and o f this into Ca l lidz'na elegans .

The truth o f the do c trine o f pangenes is has been put to a practicaltest by Mr. F . Galto nd

‘ by breeding fro m rabbits o f a pure variety, in towho se c irculation blo o d taken fro m o ther varieties had previous ly beenlargely infused ; the results were abs o lutely Oppo sed to the idea o f

pangenes is , the animals c ontinuing to main ta in in their offspring thepurity o f the breed.

Dr. Bree has published An E xpo sition o fFallac ies in theHypo thesiso f Mr . Darwin .

’

Mr. Huxley, A Manual o f the Anatomy o fVertebrated Animals .

’

Dr. Ord, No tes o n Comparative Anatomy .

’

ABSORPT ION .

In regard to ab so rption ,H. Auspitz i has made many experiments

on the abso rption o f so lid substances from the sero us cavities , us ing fo rthis purpo se starch-meal , the grains o f which preliminary o bservation sshowed to be easily rec ognised under the m icro sc o pe when injectedinto the blo o d. The grains were fo und to be taken up in theirs o lid fo rm . The presence o f o il o r fat greatly favo ured the pro ces s o f

their absorptio n . The exam inatio n o f the skin after the infricatio n o f

starch-meal salve showed the gra ins to have penetrated into the tissueo f the c o rium ,

into the subcutaneo us c onnec tive tis sue, and into the

musc les c o nnected therewith , but no t into the fundus o f the sebac eousglands o r o f the hair-fo llic les . Neumann

’

s researches with mercurialo intment showed, o n the c ontrary

,that when thi s was well rubbed into

the skin it penetrated into the hair-bulbs,sebaceo us fo llic les

,and, fo r a

short distance, into the sweat-ducts . He believes it is ab so rbed fromthese parts after a variable length o f time in the fo rm o f sublimate .

Neumann satisfied him self that rabbits abso rb c o rro s ive sublimatethrough the skin after long immersion in a bath c ontaining a small propo rtion o f that salt .Genersich

, ” in a paper on the abs o rption o f lymph by tendons and

fasc iae,shows that the ac tion o f the musc les plays an impo rtant part in

‘Month . Mic . Journ v, 2 2 2 ; vi, 184 and 2 1 7, 187 1 .

f Proceed Ro y. So c . , XIX, 187 1 .

I W iener Med. Jahrbucher,’ N . F., 187 1, ii i .W iener Med. 187 1 .

‘Ludw ig’ s Arbeiten,’ 5 Jahrg, 1870.

4 RE PORT ON PHY SIOLOGY .

caus ing the lymphatic s o f the tendon s to ab s o rb , by a kind o f suc tionpower, the lymph within and surro unding the muscular masses . He

as certained the am o unt o f lymph dis charged from the tho rac ic duct In

a given time

,bo th when the musc les were quiescent and when exc ited

to powerful and sustained ac tion by induced currents o f electric Ity,

and found that the propo rtion varied from I to 1 In favo uro f the period when the musc les were c alled into p lay . Les ser co rro

bo rates Genersich ’s results , and rec ommends the in sertio n o f a glasstube into the tho rac ic duc t o f fasting dogs fo r the pro curement o f largequantities o f lymph . He o btained in this way as much as 300 o f

lymph in a few ho urs . Hammarsten 1'

analysed the gases o f the lymphthus o btained, and fo und as much as 40 per c ent . o f carbonic ac id.

Nas sei investigated the c ircumstan ces that influence the flow and fo rm ation of the lymph . He finds that ligature o f the caro tid diminishesthe rapidity o f the current in the cervica l lymphatics , and c auses an ln

crease in the am ount o f water and a diminution in the amo unt o f fibrinin the fluid traversing them . Ligature o f the veins produced o ppo siteeffects . Irritation o f the sympathetic , o r rather o f the vago - sympathetic

,c aused a dim inutio n o f the lymph current and augmentatio n o f

the c o agul ab ility‘

o f the lymph . Sec tio n o f the sympathetic had re

markab ly little effect .G o ltz § has demonstrated, in an interesting paper, that the nerve

c entres have a direct and c ons iderable influence on the pro ces s o f

abso rption .

Po pperHhas investigated the mesenteric glands o f dogs by means o f

the chlo ride-o f-go ld metho d o f Cohnheim and Gerlac h . He finds thec apsule o f the lymphatic glands c ontains fas c icul i o f no n-medullatednerve-fibres

,from which nerves pas s o ff, which , penetrate into the s ub

stance o f the gland, where they fo rm a fine plexus , some o f the fibres o fwhich are traceable into c onnec tion with the c ell-elements . Here and

there were fo und stellate cells resembling ganglio n-cells .

Dr. E . Klein and Dr. Burdon Sanders o nfil in a paper on the no rmaland patho logical histo logy o f serous membranes

,describe the arrange

m ent o f the lymphatic s in them . They Show how the lymphatic sc ommunicate at various po ints , no t o n] by true stomata

,b ut also by

means o f pro to plasmic pro c esses o f the Tymph -canal-cell s which run tothe surfac e between the endo thelial cells with the sero us cavity . Theselast they c all pseudo -stomata . In a later number“ o f the same journa lDr. Lavdowsky lays c laim to the

'

merit o f being the o riginal dis c o verero f the true stom ata , and the same histo logical feature was o bserved byDr. Winogradowfi

' in the amn ion .

RohrigII shows that various sub stan ces,as turpentine, s o lution o f

Berichte der kOnig. Sach s . Gesellschaft der 187 1.f Idem , 187 1 .

I Henle und Meis sner’s Bericht fur 18 1 2 1 .

Pfluger’s Arch iv, ’ v, 1 .

Arch ives o f Medic ine, ’ v, 46.

WT ‘Centralb latt,’

No s . 2 , 3 , and 4, 1872 .

H “ N o . 1 7.

H' ‘Rudnew’s Arch iv, ’ iii, 187 1 , 1 .

II‘Arch iv d . Heilkunde, ’ 1872 , XIII, 34 1-388.

BLOOD. 5

io dide o f po tassium ,&c .

, can b e abso rbed thro ugh the unbroken skin,

espec ially if applied under presOther papers are by E icho rst U eber dieReso rption der Albuminate

im in Pfliiger’

s Arch iv,

’

187 1 , 5 70 -662 . Heiberg Saft

c anal system der in N o rdiskt Med. Ar chiv,

’ iii, 4,

and Laqueur U eber die Durchgangigkeit der Hornhautnfur Fluss ig

in Oentralblatt,

’No . 3 7, 187 2 .

BLOOD .

The m o st impo rtant treatise that has appeared upon the blo o d is thato f Preyer =x= on the crystals o f the blo o d, o f which the reader will findan analys is in ‘Humphry and Turner’ s Jo urnal o f Anatomy

,

’ by Dr.

Rutherfo rd,and ano ther in the Medic o -Chirurgical Review’

fo r 1872 .

Preyer finds haemoglobin in a ll vertebrates , in one m o llus c (Plano rbis) ,two arthro pods , and two wo rm s . It is n o t present in echinoderm s

,

c oelenterates,pro to zo a, o r p lants . It exists independently o f the

blo od in musc le . T he eas iest, tho ugh no t the best, m o de o f pro curinghaem oglo bin -crystals is to deflbrinate dogs ’ blo od and m ix it with o ne

and a half times its weight o f c o ld water. Af ter three hours add a

quarter o f its vo lume o f rectified spirit . This fluid,if left fo r a night

in a freezing m ixture, will b e fo und to c ontain crystals in the m o rn ing,which should b e washed with a little pure water . Pure haem oglo bin isvery inso luble . Al l the fo rm s o f its crys tals belong either to the rhombic(man

, guinea-

pig, and m o st mammals) o r to the hexagonal (squirreland some ro dents) system . All doubly refrac t light . Haem oglo bingives o ne abs orption band ; when c ombined with oxygen it gives two .

He gives its fo rmula as CGOOH960N154Fe

1,83 , 0 179 . It can be broken up

into album ino id c ompounds , pigm ents,and ac ids .

M . Brondgeest 1” found a variable number o f c o lourles s crystals in the

blo od o f frogs kept fo r some time at low temperatures . Their formwas

,fo r the m o st part

,prismatic , with very long lateral surfaces and

pyram idal extrem ities , no t, therefo re , agreeing with any known fo rm o f

b lo o d-crystals . They are inso luble in water and in ether,so luble in

dilute ac ids and alkalies,and in a 5 per cent . s o lutio n o f c omm on salt .

They are very stable . When dried they m ay be kept fo r years unchanged in appearance . They do no t fo rm as the blo od thaws, butmayb e seen in the fro zen blo od. They canno t be o btained from c o agulatedblo od. They are m o st abundant and best seen in animals that havebeen fro zen into a so lid blo ck at a temperature o f 4

°Cent

,and then

submitted to a c on s iderably lower temperature . Brondgeest believesthem to be derived from albumen .

Struve, o f T iflis ,i has demon strated the presence o f two c o louringmatters in blo od . One o f them is extremely s o luble in water and

alc oho l,but with some difficulty in ether

,and no t in ac ids . The ashes

c ontain s ilic ic and ph o spho ric ac ids,oxide o f iron

,and a little alkali . It

gives a blue c o lo ur with tincture o fguaiacum and turpentine . It appearsDie Blut-crystal le,’ Jena, 187 1, 263 .

1' ‘Arch iv f . GeneeS -en-Naturkunde, ’ 1870, 3 78.

1 Virchow’

s Arch iv,’ lvi, 1872 , 4 2 3 .


to b e identical with Prey er’s alkaline o xy-haamatin o r V . W ittich ’

s

hwma tin . The sec ond kind o f c o louring m atter fo rm s small, dark, blueblack, m icro sc opic crystals

,inso luble in water, alc oho l, ether, chlo ro

fo rm , and ac ids,but readily so luble in a lkal ies . From it haem in

crystals can b e readily prepared . It appears to be identical withVirchow’

s kwmatoz’

dz’

n .

Stras sburg’s experiments c o rro borate the statements o f Pfluger andZuntz that on the addition o f ac ids to blo o d the haem oglobin undergo es

o xidation and Splits into haematin and albumen .

Ado lf Jarisch 1° gives the fo llowing as the arithmetical m ean o f four

careful researches o n the c ompo s ition o f the ashes o f the blo o d o f the

dog z—Pho spho ric ac id anhydride per cent . , sulphuric ac id anhy

dride chlo rine po tash soda lim e magnes iao xide o f iron per cent .

Dr. J . Richards on}: c on c ludes , from his experiments, that the whiteblo o d-c o rpusc le is a cell c ompo sed o f a c ell-wall with c ontents and a

nucleus (o r nuc lei) , which po s ses ses the power of vo luntary am oebo idm o vement

,is s o luble in water, but is capable o f slowly im bibing that fluid

and increas ing to nearly do uble its no rmal size . The cell-wall o f the c o rpusc le is a m embranous envelope, inso luble in water, to o thin to exhibit adouble c ontour with a m agnifying power o f 1 2 00 diameters , but firmeno ugh to restric t the m o vement o f its c ontained granules . Its exterio ris som ewhat adhes ive, so that surfaces o r partic les c om ing in c ontac t withit are liable to bec o me attached thereto . Some phenomena o bserved lendc ountenance to a theo ry that this membrane is do tted with m in utep o res , which perm it delic ate threads o f the s o ft pro to p lasm to be ex

truded, and the edges o fwhich , if the projection still c o ntinues during theam oebo id m o vement, are c arried o utwards as a sheath to all except the

extreme po int o f the narrow tongue-like pro ces s . The m aterial o ccupying the space between the capsule and the nuc leus

,denom inated the

pro to plasm o f the c ell (the fibro -

p lastin o f Pro f. Heynsius) , is a so ft,

jelly-like m atter, in which the p ower of am oebo id m o tion res ides . Itappears to be so luble in water and saline so lutio ns in all pro po rtions ,and when freely diluted lo ses its amoebo id power, which , however, isregained in a m aj o rity o f cases when the exces s o f fluid is withdrawn .

The laws by which leuc o cytes take up and part with liquids seem to

b e simply tho se o f the dialys is o f fluids through an imal membranes byendo sm o s is and exo sm o s is

,as studied by Graham

,on a larger scale, in

1855 .

Jurasz § has investigated the action o f bile and the biliary ac ids uponthe blo od-c o rpusc les , and finds that the white co rpusc les res is t theaction o f bile better than the red

,hence the greater number o f the

fo rmer in the blo od o f the hepatic vein .

Manas sein, ” from the results o f numerous c o rn measure

ments , finds that the size o f the red c o rpusc les dimm l shes in septicaem icPfluger

’

s Arch iv, ’ iv , 454 .

“

l Stricker’ s Med. J iv, 187 1 .

I Pamph let, 187 2 .

Inang . Dissert. Greifswald, 1871 .

Centralb latt,

’

No . 44, 187 1 .

:B14E5D. 7

po isoning during expo sure to a high temperature and to an atmo spherec o ntaining an excess o f carbonic ac id ,

whilst they enlarge under the

influence o f o xygen ,and by the actio rio f agents lowering the tempera

ture o f the body, as c o ld, quinine, hydro cyanic a c id,and a lc o ho l .

The ac tion o f quinine upon the white c o rpus c les o f the blo o d hasbeen studied by Geltowskyfi? Kerner,

°

lLand Bin z I All agree in stating

that it renders them round,darkly granular, m o tionles s , and unexc itable .

Dr. A . Marc et§ maintains that blo od is a c o llo id fluid, but that italso c onta ins 7 °

3 per 1000 o f difl'

usib le c onstituents . T he pro po rtiono f difl

'

usib le c on stituents in serum is these quantities diffusingout in twenty-four ho urs . The pro po rtion o f chlo rine is remarkablyunifo rm, being per 1000 . Blo o d c ontain s pho sphoric anhydrideand peroxide o f iro n in a perfectly c o llo id state.

Schm idt ” devo tes a long paper to the c on siderat ion o f the cause o f

the c o agulation o f the blo od. He c o ns iders that, bes ides the fibrinogenous and the fibrino plastic substances , a third substance o r fermentmust be present ; this Is generated either In the white co rpus c les o r inthe plasma , but no t in the red c o rpus c les .

Schifl’

er fil demonstrates that n o c o agulation o f blo od takes place inthe living vessels, even though c on siderable quantities o f free fibrinoplastic7sub stance be injec ted into them .

Bo ll“ finds that,owing to defic iency o f fibrinogen, the blo od o f the

foetal chick does no t c o agulate befo re the twelfth o r fo urteenth day,and then o nly imperfec tly . Haem oglo bin can be distinguished by theSpectro sc o pe in the blo od on the third day o f in cubation . Kleinfi

'

describes the develo pment o f the earliest blo od-ves sels and c orpusc les .

Boyd Mo ss ++1: describes a peculiar c iliated haemato zo on ,

which he foundo n several o c cas ions in the blo o d o f the Ceylon deer (Muntjac) , and T .

R . Lewis § § describes a peculiar kind o f Filaria as being c onstantlypresent in vas t numbers In the blo o d o f patients affectedwith Chyluria .

The views o f Waller and Co hnheim respecting the o rigin o f pus

globules from the wh ite c orpusc les o f the blo o d have met with an

Opponent In Dr. Duval who,from the results o f his experiments upon

the c o rnea,has arrived at the c onc lusio n that the pus

-c o rpusc lesappearing in severe inflammation o f that membrane result from the

pro liferation o f the plasmatic cellules o f the c o rnea l tissue , and not fromthe white c o rpuscles .Lo sto rferfiHl has published some observations on the presence of fungi

Practitio ner,’ June, 1872 .

f Pfluger’

s Arch iv, ’ v, 2 7 .

I Prac titioner,’ Sept. 187 2 .

‘Nature,’ May 18, 187 1 .

Pfluger’s Arch iv, ’ vi , pts . 8 and 9.

fll‘Centralb latt,

’No . 10 , 1872 .

“ i Reich ert und Dub o is Reym ond’s Arch iv, ’ 1870, 7 18.

H' S itz . der Akad. der Vienna, 1871 and Humphry and Turner’s Journal , ’

11 Month ly Mic . 187 1, vi, 181 .

Pam ph let , 1872llll Brown Sequard’ s Arch ives de Phys io logie,’ 1872 , 1 76.

fllfil‘ Stricker’s Jahrbucher,’ 1871, 45 1 1872 , 96.


in the blo o d o f man ,showing that the germ s o f the sarc ina ventriculi,

o r o f a fungus which when cultivated is so c lo sely al hed to It as to b e

indistinguishable from it,exist in no rmal human blo o d. He has alsowritten a paper to demon strate the presence In the blo o d o f syphilitl c

p atients o f peculiar c o rpus c les . HIS statements are endo rs ed by the

high autho rity o f Pro f. Stricker, but have met w1th great o ppo s ition 111

Germanyfi“

ChalvetT gives the fo llowing analysis o f the blo od In scurvy —Fibrin4 per cent . ; c orpus c les 63—100 per 1000

,Instead o f 130 per 1000 ;

water 853 °

5 , instead o f 779 ; albumen per 1000,Instead of the

normal 687 .

Laschkewitz i describes the red c o rpusc les In a case o f Addison ’

s

disease, large , pale, and presenting am oebo id m o vements .Mo sler § states that during life the blo od o f a highl y leucaemi c patient

was alkaline it only became ac id after dea th .

Hoppe-Seyler finds that white blo od o r lymph-co rpusc les c ontainglyc ogen s o long as they exhibit mo vements, but when they becomerigid they lo se their glyc ogen and c ontain sugar.

Other papers o n the blo od- c o rpusc les are by E .

.

Ray LankesterQuart . Journ . Mic . O ct. Geo rge Gulliver (idem ,

Jan .

Braxton Hicks (idem ,April , and No rris Transac t . S t .

And. Med. Grad. N o rris c o nsiders that in pas s ingthrough the capillary walls the mo rpho logical elements o f the blo odo bey the same physical laws as so ap -bubbles . Diantegaz za Centra lblatt, ’ 187 1 , N o . Ho ppe-Seyler and Mieschen On the Chemica lCompo s ition o f Pus and Pa s-c o rpusc les, ” ‘Mediz . Untersuchungen ,

’

187 1 , pp .

Other papers are—P . Q . Brondgeest, Over ongekleurde Kristallenin het blo ed van bevro ren Kikvors chen ”

(o n the pre senc e o f c o lo urles scrystals in the blo od o f fro zen frogs), in the

‘Nederlandsch Archiv.vo o r Genees -en-Naturkunde

,

’

1870 , v, 3 78, with a plate . M . Preyer,Synthese des ro then Blutfarb -stofl

’

s aus seinen Zersetzungsproducten”

(synthes is o f the red c o louring m atter o f the blo od fro m the roductso f its dis integration), in the Centralb latt fur die Medicin . is senschaft,’ N o . 1 0

,187 1 . E xner

,On the Develo m ent o f Amm onia in

Dec ompo s ing Blo od, ” Sitzungsber. d. K. Aka zuWien,

’ lx ii,ii, 363 .

W . Marcet, On the Con stitution o f Blo od and Nutrition o f Tiss ue,

British Medical Journal, ’ June 1 7, 187 1 .

CIRCULAT ION. HEART . ART E RIE SF .W. Beneke fil gives the fo llowing as the results of nearly a hun

dred measurements o f the arteries o f adults —1 . The internal c ircumSee for vari ous papers o n th is sub ject Va ida and Biesiadecki in ‘Wien . Med .

Wo chens . Ko hner, ‘Berlin Klin . 1872 , NO. 18.

f Union Médicale, ’ 187 1 , No . 1 2 1 .

1 Die ro then Blutko rperchen in einem Fa lle von Morbus Addiso nn .

’

Die Reaction des leukam ischen Blutes .

Med. Chem . 486.

fll Jahrbuch . f. Kinderheilkunde, ’ N . F . ,iv

, 380 .

CIRCULATION . 9

ference o f the aorta 1 c entimeter abo ve the valves,maximum 58 8

m illimeters, m inimum 3 I°

0 m illimeters ; difference, mm . 2 . In

ternal c ircumference o f the descending tho rac ic ao rta 1 2 cm . below theorigin o f the left subc lavian ,

max. mm . ,min . mm . difference

,

2 7°

5 mm . 3 . Internal c ircumference o f the abdom inal ao rta 3 cm .

above the bifurcation ,m ax . 3 mm .

,m in . mm . ; differen ce, 2 0 1

mm . 4 . Internal c ircumferenc e o f the pulm onary artery 2 cm . abo vethe valves , max . 58 0 mm .

,m in . mm . ; differenc e , 2 73 mm . The

smallest diameter o f the arterial ves sels was fo und m o s t frequent ly incases o f chronic pneumon ia and tuberculo sis .

Cyon and Steinmann’x‘ find that the rapidity o f the current o f blo o d

in the veins is nearly as great a s in the arteries,and they des cribe the

c onditions which lead to variation in the rapidity o f the current .Dr Mies cheri

°

c onduc ted experim ents to determ ine what influen c esection with preservation o f c ertain po rtio ns o f the spinal c o rd exerc isedupon the reflex action of certain nerves aris ing below the lesion upon

the blo od pres sure . He c o nc ludes that the centripetal fibres o f the

s c iatic nerves capable o f reflecto rially in creasing the blo o d pressurerun (in that po rtion o f the medulla which extends between the thirdlumbar nerve and the last do rsal) either entirely o r princ ipally in the

lateral’

zwhite m edullary c o lumn s o f the c o rd. Again ,he finds that in

the same region o f the co rd the c entripetal fibres o f the left s c iaticchiefly run in the right and in sma ller pro po rtion in the left latera lc o lumn , and vice versé . Lastly

,he shows that the fibres o f this nature

c om ing from the lower regions o f the c o rd,run in its outerm o st portion ,

whilst tho se that enter at the higher planes run who lly o r partially inthe neighbourho od o f the m edian plane .

Ceradini,I T . Lauder Brunton ,§ and Pick

,“ have investigated the

effects of heat on the action o f the heart.A . H. Garro d has published a paper on the construc tion and use o f

a simple cardio -sphygm ograph fil and an o ther o n the mutual relationso f the apex cardiographic and the radial sphygm ographic traces . “The remarkable increase in pressure in the arterial system o c curringwith stoppage o f the resp iration is generally ac c ompan ied by increasedvascular c ontractio n

,and MM . Dogiel and Kowalew sky

"H' have Shownthat in curarized dogs there is also a c o inc ident decrease in the rapidityof the arterial current in the crural artery.

Gatzuck’

s o bservations 11: made on dogs show that venaesection,

espec ially from the anterior extrem ities, retards the mean velo c ity o f thecurrent o f blo od in the caro tid and crural arteries and their branches

,

and, generally speak ing, the mean pres sure also falls , though it o c cas ion

ally remains unaltered Or even augments . The quantity and rapidityBull . de l ’Ac ad . des Sci. de St. Petersb ourg,

’xvi, 2 66.

1 Ludwig ’s Arb eiten ,

’

sth Jahrg .

I‘IIMecan ism o delle Valvo le Sem ilunari del Cuo re, ’ Milano , 187 1 .

St. Barth o lomew ’s Ho sp ital Reports, ’ vii, 2 16.

Pfluger’s Arch iv,’ v, 38.

fil Humphry and Turner’s Journal , ’ v , 2 65 .

W “ Pro ceed. Roy. xix, 3 18.

“H Pfluger’s Arch iv, ’ i ii, 489 .

II‘Centralblatt,

’No . 53 , 187 1 .


o f the blo o d discharged powerfully influence the result . When the flowo f blo o d has ceased, bo th the rapidity o f the c urrent and the pressurequickly return to their no rmal am o unt . W ith the dim in ished velo c ityand pressure o f the b lo od current the frequen cy o f the heart

’

sc

beats

augments

,the so unds (espec ially the second) are dim inished in inten

sity , and the temperature o f the bo dy falls 2°o r 3

° Fahr.

M. N o letfi“ in investigations made to determine the nature and cause

o f va scular murmurs , finds that a sound is produced even in a tube o f

unifo rm calibre, pro viding the rapidity o f the current be sufliciently

great . Thus , in a thick-walled tube o f caoutc houc having a diameter o f

about 2 -3rds o f an inch mm ) , a bruit becomes audible when therapidity o f the current was about five and a half feet a sec ond ( 16001 700 T he smaller the tube the greater the velo c ity required topro duce a bruit. Greater velo c ity was required with meta l tubes thanwith caoutchouc , in c onsequence o f their greater smo o thness . T he

presence o f a c onstric tion caused a bruit to beco me audible with greatlydim in ished velo c ity o f current, the so und being pro duced bo th befo reand beyond the c onstriction

,but chiefly beyo nd. The presence o f a

dilatation also causes a bruit, but the velo c ity o f the current must begreat . The larger the dilatation the greater the rapidity o f currentrequired, hence the absence o r dim inution o f murmur in large aneurism s .

The sound is m o st audible at the entrance to the dilatatio n,and in all

cases the bruit is due to the fo rmation o f eddies .Dr. Mayeri' has investigated the ac tion o f strychnine o n the blo o dpressure, and finds that it immensely augments it, which he attributesto its exc itant action on the vas o -mo to r centre in the cerebrum ,

caus ingc ontrac tion o f the smaller arteries, and no t to the tetanic co nvulsio nso f the vo luntary musc les .

Ewald B eringi from his experiments o n dogs , shows that moderateexpansion o f the lungs by insufliation through a canul a in the trachea ,which is then c lo sed, causes increased rapidity o f the heart ’ s . actio n .

He pro ceeds to dem onstrate that this effec t is no t due to the in creasedpres sure exerted upon the external surface o f the heart

,no r to altera

tions in the c o ndition o f res istance in the difl'

erent parts o f the c irculation, nor to differences in the interchange o f gases , no r to any dislo c atio no f the heart ’s po sitio n

, but that it is effected reflecto rially thro ugh thevagi . The insufiiation

,he thinks, exc ites certain senso ry fibres o f the

lungs , and these stand to the cerebral centre o f the inhibito ry fibres o fthe heart in the same relation that the fibres o f the depress o r nerve doto the cerebral centre o f the vaso -mo to r nerves . Bo th o f these centres

are in a state o f c onstant exc itation,which is lowered by the irrita tio n o f

the abo ve-mentioned fibres . These fibres are therefo re to be regardedas inhibito ry nerves fo r these c entres . Fo r o ther papers see 0 .

S chm iedeberg, researches on the ac tion o f certain po iso ns (mus carin ,

atropin,daturine) on the heart o f the frog. §

3“ Beitrage aus dem Physio log . Lab orat. zu Leiden,

’187 1 .

1 Studien zur Physio logic des Herzens und der Blutgefas se, Dr. Sigmund Mayerin Stricker’s Jahrbii cher, ’ 187 2 , 1 I 1 .

I Stricker ’s Jahrbucher, ’ 187 2 , 3 7 .

Ludwig ’s Arb eiten, ’ sth Jahrg.

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o f rapidly supervening fatigue o f the muscles , which c eased to respondto the m o st vio lent exc itement o f the respirato ry centres produced by thecyano sed blo o d. In a strong rabbit sim ilar dyspnoea o ccurred

,b ut the

number o f respirations ro se from 3 2 to 48, and graduall to 77 , in c ousequence o fthe greater vigo ur o f the musc les . In bo th ra hits the am o unt

o f air breathed diminished to about one half, even the greater rapidityo f the resp irato ry mo vements o f the stronger rabbit no t c ompensatingfo r the abs o lutely smaller quantity inhaled . (3) In a third set o f

experiments the tracheal tube was narrowed s o as to dimin ish thequantity of air adm itted ; the number o f the respira tio ns was immediately diminished, theirdepth was increas ed, but a smaller vo lume o f air

was actually respired. (4) In ano ther series o f experiments the effec t o fthe ab strac tion o f blo o d was investigated. These showed that, as m ighthave been expec ted, the dim inution in the number o f o xygen-c o nveyingblo o d-c orpus c les o c casioned in the first instance dySpnoea ,

but the same

absence of red c orpusc les so on reduced the in terstitial changes in the

tis sues,a les s supply o f o xygen was needed, and co nsequently the re spi

rato ry vo lume dim inished. U ltimatel the dis integratio n o f the tis suesand the abso rption o f o xygen was s o flair lowered that death to ok plac e .

(5) In the fifth series Leichtenstern injec ted half a grain o f mo rphiaunder the skin o f the back . This dim in ished the number o f the respiratio ns as well as their depth , and, therefo re, the vo lume o f the respiredair

,fo r the first half hour. Then the number o f respiratio ns ro se, and

after a time and to a certain extent the vo lume inspired, tho ugh no t tothe no rmal am ount . V . Bezo ld thinks these effects due to lowered ex

c itability o f the respirato ry centre , but it may als o be due to diminishedtis sue change, just as o c curs during s leep . Leichtenstern thinks bo thc auses o perate . (6) T he effec ts o f sec tion o f the spinal c o rd betweenthe third and fourth cervica l vertebra were exam ined. T he number anddepth o f the respiration s were fo und to b e remarkably dim in ished ; thisis owing to dim inished metamo rpho sis o f tis sue , which , again ,

Leichtenstern thinks is attributable to the paralys is o f the blo od-vessels andlowered blo o d pres sure thro ugho ut the sys tem . (7) The effec ts o f c o ldwere examined. and it was found that immediately after expo sure

,befo re

the general temperature o f the body c o uld have undergo ne any change ,

the number and depth o f the respirations underwent great increase, andthis even when the animal was wrapped up in warm c lo ths

,showing it was

due to the exc itation o f the vagi in the lungs . When the c o ld ac ted fo rs ome time, s o that the general temperature sank

, the number o f therespirations fell gradually below the no rmal amount

,tho ugh their

increased depth was maintained fo r some time . (8) E xperiments werem ade on the action o f heat on the vo lume o f the res pired air, and it wasfound that the expo sure to heat caused quickly a s light inc rease in thnumber o f the respiration s , owing, probably, to exc itatio n o f the v inthe lungs and the cutaneous nerves but further augmentation o f the eatdid no t increase their number till it became very high , when bo th theirnumber and depth increased, apparently because high temperaturesaugment ti ssue metamo rpho s is . (9) And lastly, a series o f experimentswere made on the vo lume o f the respired air after the cutaneo us respiration had been suppressed by c o ating the animal with linseed o il . Leich

RE SPIRATION AND ANIMAL HEAT . 13

tenstern c o rroborates the experiments o f Las chkewits ch and Krieger,that death results in these c ases from c o ld

,and the phenomena o f the

respiratio n c o rresponded with tho se o bserved in c o ld.

Quincke and Pfeifi’

er’x‘ show that with each insp iration the passage

o f the blo od through the left ventric le is ac celerated.

Schiffj° maintains that sec tion o f the lateral c o lumn s o f the c o rd at

the level o f the first c ervical nerves arres ts the respirato ry m o vementso f that s ide . He states also that

,the lungs and vagi being rem o ved

from the body, elec trical exc itation o f the vagi causes c ontraction o fthe

parenchyma o f the lung.

Lando is + and Ceradini§ have experimented on the action o f the hearton the respiration . The fo rmer finds that some air is expelled witheach systo le o f the heart, the latter that the effec t i s m o re c omplicated.

The o ppo s ite investigation , viz . the ac tion o f the respiration on the c ir

culatio n, has been pursued by Dr. HeringE xperiments made in 1865 by MM . E sto r and St. Pierre seemed to

show that a c ons iderable quantity o f o xygen disappears from the blo o d,

even whilst pas sing thro ugh the . larger arteries . This statement is ,however

,co ntested byMM .Mathieu and D ’

U rbainAl who m a intain thatthere is s carcely any apprec iable differen ce in the am o unt o f o xygenc ontained in the blo o d o f the caro tid and crural arteries ; they have,however, fo und that when the difference in the s ize o f two vessels isvery great the blo o d c ours ing thro ugh the larger one c ontain s m o re

o xygen and les s carbonic ac id. In a sec ond paper, in which they givethe results o f their experiments o n the influence o f external temperature on the am ount o f gas c ontained in arteria l blo od, they Show thatin warm -blo o ded an imals the quantity o f oxygen abso rbed by the blo odvaries inversely with the temperature o f the air they breathe, being in

creased in winter and dim inished in summ er. This is c o nfo rmablewith the physic al fact that the exchange o f gases through a m o istanimal membrane is m o re rapid at a low than at a high temperature .

M . Paul Bert“ has studied,in the phys io logical labo rato ry o f the

So rbonne, the influence that changes in the barometric pres sure exerc iseon the phenomena o f life . When warm -blo oded animals are suddenlyexpo sed to air s o rarefied that it will only suppo rt 15 to 18 centim . o f

mercury,c o nvuls ion s, fo llowed by death, are rapidly induced, with the

appearance o f blo o dy fro th in the bronch i . If it be do ne by degrees ,however, they will live in a very rarefied air (1 2 centim .) fo r s o me

time,tho ugh all ultimately die from asphyxia . Birds canno t live at a

lower pres sure than 18 centim . The lower the pres sure the m o re

oxygen remains unexhausted.

Hermann Aubert, o f Ro sto ckd’ l‘ finds that the to tal amount o f car

Reichert und Dub o is Reym ond’s Arch iv, ’ 187 1 .

1° Pfli

’

i ger’s Arch iv, ’ iv, 2 2 5 .

I ‘Berl in Klin . 1870, 9 .

Annali Un ivers ali, ’ iv, 587 .

‘Sitzungsber. der K . K . Akad. zu W ien,

’ lxiv.1T Brown -Sequard’ s ‘Arch ives de Phys i o logie, ’ 1872 , 190 and 304.

‘Rev . 2 de sér. , 1, 166.

ff‘Pfluger

’s xi.


b onic ac id eliminated from the skin o f the who le bo dy in twenty-fo urhours

,at a temperature o f 86

° Fahr. ,is abo ut 4 grammes , o r 60 grains ,

whilst the amo unt o f that given o ff by the lungs is , perhaps , 90 0grammes , or grain s .

Dr. Bern stein’t remarks that no attempt has hitherto been made to

c o nstruct an apparatus appro ximatively resembling the c ondition s underwh ich an exchange of gases takes place in the p lacenta . He gives thedetails and a drawing o f an ingen ious in strument he has c onstruc tedwith this object in view, and shows that the exchange o fgas es disso lvedin fluids is extremely small .Schifi

’

i° has made many researches on the influence o fartific ial respira

tion having an important bearing on the preservation o f life in couous

sion and compres s io n o f the brain and o n the c irculation .

Arthur Ransome,I in a paper on the m echanica l c onditions o f the

resp irato ry m o vements in man,shows that the c lavic les have mo re

upward than fo rward m o tio n,and m o ve less than either sternum o r

ribs . The ribs mo ve upwards mo re dec idedly than the sternum , and

the upward dimen s ions o f the respirato ry m o vement o f the chest,as a

who le, are suflic iently acc ounted fo r by the upward ri se o f the ribs, theircho rd length being taken as radius

,their vertebral attachments as

c entres . The o utward indications,as given by the s tethometer, are also

pro bably to be ac counted fo r by the s imple radial rise o f the co sta lends o f the c o stal c artilages , the sternal articulatio n being taken as

c entre . The extent o f the forward indicatio ns may be ac c ounted fo reither on the hypo thes is o f the ribs bec oming straightened in inspiration o r o f their being previously unbent in expiratio n. As regardsthe actions o f the interc o stal musc les

,the external interc o stals ( I) draw

the ribs upwards , (2 ) separate their anterio r ends , 3) straighten them .

On the o ther hand, the action o f the internal interco sta ls is ( 1) todraw the ribs downwards

, (2 ) to bring their anterio r extrem ities nearertogether, (3) to bend them inwards . The diaphragm also bends in thelower ribs .

Mr. F . Le Gro s Clark § has also discussed somewhat fully themechan ism o f respiratio n , especially showing the impo rtance o f thepas s ive tens ion o f the diaphragm .

Dr. Rattray | | enters into some interesting details in regard to them o re impo rtant phys io logical changes induced in the human ec o no myby change o f c limate . He conc ludes that natives o f c o lder c limates ,and espec ially the young, debilitated, and diseas ed, should leave thetro pic s , particularly during the rainy season . E ven adul ts sho uldleave them if they lo se flesh and strength , and frequent change to m o re

benefic ial c limates o r higher altitudes is advisable fo r all who livein them . He c onc ludes also that the primary effects o f great changeso f c limate is on the c irculation

,the blo od being drawn surface-ward by

heat and driven inward by c o ld, hence a difference in the relative‘Ludwig ’s Arb eiten,

’1870, 5 th Jahr

1° ‘Centralb latt,

’1872 , 756.

gang

3: Pro ceed. Roy. xxi, 1 1 .

Meet. Roy . So c iety,’ May 2 5 , 187 1 .

‘Pro ceed. Roy . 187 1, x1x, 2 95 .

DE GLUTITION . 15

activity o f the external and internal o rgans , the function o f the skinaugmenting, tho se o f the lungs and kidneys dim in ish ing . The

resp iratio n and c irc ulation are bo th m o re languid, yet the temperaturerises about 2 ° F .

G . v . Liebig" c o ntributes a paper on the influence exerted upon theresp iration by increased o r dim inished atm o spheric pres sure . He

finds that res idence at high altitudes has a tendency to develo p therespiratory power and the strength generally, hence it is useful in all

c ases o f dim inished elastic ity “ Fo r o ther papers o n respiration see

G ustav Stras sburg i' H . Sanders E zn , on apnoea and dyspnoea }:L . G o ldstein .§ F . Kratschmer. ”Wo lfl

'

beyfl finds the arithmetical m ean o f the tensio n o f the carbon icacid in the alveo li o f the lungs to be and the tens io n in that o f theblo od to be per cent .C liffo rdAllbutt“ has c ontributed a paper on the effect o f exerc ise on

the bodily temperature , showing in o ppo s ition to M . Lo rtet that theregulating p ower o f the o rgan ism ho lds go od under great variations o f

mus cular ’

exertion ,tho ugh once o r twice l ow temperatures were n o ticed,

perhaps attributable to s ome ac c idental defic iency in c ombustion .

Fo r o ther papers see Ransomefi'

l'

and espec ially Ho rvath . jlji

DE GLUT IT ION .

T he subject o f the nerves presiding o ver deglutition has been care

fully investigated by MM .Waller and and they sum up theirresults in the fo llowing words —( I ) Feeble induc ed currents appliedto the central extrem ity o f o ne o f the superio r laryngeal nerves after

division cause arrest o f the m o vements o f the diaphragm in expiratio n ,

as stated by Ro senthal,and rhythm ical m o vements o f deglutition . (2 )

Mo vements o f deglutition m ay be pro duced by irritation o f the centra lcut extrem ity (a ) o f the recurrent nerves ; (6) o f the vagi , when the

irritation was made abo ve the o rigin o f the superio r laryngeal nerves(c ) o f the glo s so -

pharyngeal (at least in the dog and eat,but no t in the

rabbit) . 3) On laying o pen the buccal pharyngeal and laryngealcavities , with a view o f determ ining what nerves exc ite m o vements o f

deglutition on being irritated, and the results o f dividing the severalnerves succes s ively

,they found that in rabbits (a) the glo sso -

pharyngea l

‘Arch iv f. Klin . vi ii, 445 .

1° Pfluger

’s Arch iv, ’ vi, 1 , 65 .

t Maandb lad voo r Natuurwetensch apen,

’1870 -7 1, 1 13 and Centralblatt,

’

187 1 , 5 1 1 .

Ueb er Warmdyspno e,”Centralb latt,

’1871 , 678.

Ueb er Reflexe vo n der Nasen s ch leimh aut auf Athmung und Kreislauf, ” Cen

tralb latt,’187 1 , 58.

1I Pfluger’s Arch iv, ’ 1872 , 2 3 , Ueb er die Athmung der Lunge.

Pro ceed. Roy . xix, 289, 187 1 .

‘H' On th e Organic Matter o f Human Breath in Health and Disease,” ‘Journalo f Anatomy, ’ 1870 , No . vi .II Centralb la tt,

’1872 , No s . 45 , 46, and 47 .

‘Brown -Sequard’s Arch ives, ’ 1870, 185 and 3 23 .


nerve exerts no reflex influenc e upon these m o vements ; (6) that thefifth nerve an imating the velum palati is the princ ipal sens o ry nervepresiding o ver deglutition ,

since after sec tion o f one o f the fifths deglatition c ould no longer be pro voked by exc iting the c o rresponding halfo f the velum palati (e) that the superio r laryngeal nerve contri butesto the reflex actio ns o f deglutition by its senso ry branches distributedt o the mucous membrane c o vering the glo ttis, the aryteno

-epiglo ttideanfo lds

,the superio r bo rders o f the laryngeal cavity, and chiefly by tho se

distributed o ver the c o rniculated cartilages ; (d) the recurrent nervea ids in the reflex phenomena o f deglutition by its sen so ry branches .

(4) In the cat and dog c ough is o ften o bserved on elec trifying thetrunk o f the superior laryngeal nerve and that o f the glo s so -

pharyngeal .In the rabbit c o ugh is o ccasionally observed on irritation o f the latternerve .

M . E bstein * has arrived at the conc lusion that the glands o f thepylo ric region o f the stomach

,fo rmerly believed to secrete mucus ,

really produce gastric juice like the true peptic glands, and have an

epithelial lining o f the same nature . T he mucus o f the stomach hebelieves to be fo rmed by the cell s c o vering the general surface .

Friedinger,°

l‘

as the result o f his researches o n vario us clas ses o f

animals, arrives at the c onviction that the o lder views were co rrec t,and

that,in o ppo s ition to the statements o f E bs tein ,

the investing cells o f

Heidenhain , o r delom orphous cells o f Ro llett, are tho se which rea llyc ontain and fo rm the peps in .

See also G . Schwalbe,IR . Wiedersheim .§Fick | | regards the peptones as c ompounds c apable o f easy dis integration, and a s supplying by their non-n itrogenous c onstituents the c om

b ustible materials fo r the mus cles and o ther o rgans , their n itrogeno usConstituents being speedily elim inated from the bo dyPas chutinfil demonstrates that the presence o f a large quantity o f thepro ducts o f the metamo rpho s is o f starch

,as

,fo r instance

,o f dextrine

and grape sugar, do es no t interfere with the actio n o f ptyalin o n

s tarch .

M. Lepine* * finds that a ferment capable o f c onverting starch intosugar is widely distributed thro ughout the bo dy, the o nly o rgan in

which it appears to be to tally absent being the c rystalline lens . It ism o st abundant in the blo od

,muscles , spleen, vitreo us humo ur, testis ,

and brain .

DIGE ST ION .

T he phenomena of peristals is have been reinvestigated by G . v .

Centralblatt,’187 1, No . 6, and Pfluger

’s Arch iv, ’ iv, 1872 , 1 .

1° W iener Akad. lx1v, 187 1 .

I‘M . S c liultze

’s Arch iv, ’ V 111, 9 2 ,

“ Beitrage zur Kenntniss der Driisen in denDarmwandungen, insb esondere der Brunners chen Dru sen .

”

‘Die feineren Strukturverha ltnis se der Drusen in Muskelem agen der V Ogel,’

Inaug . Dissert., ab s trac t in Centralb latt,’1872 , 2 78.

Pflii ger’

s Arch iv,

’ v , 1 .

1T‘Centralb latt,

’

187 1, 372 .

Ludwig’ s Arbeiten, ’ 1870.

DIGE STION. 17

Brakelfi“ who maintains the existence o f bo th peristaltic and o f antiperistaltic m o vements, and states that if a lo op of the intestine o f a cat

be pinched a wave may be fo llowed in bo th directions, travelling as faras to the pylorus and to the ileo -caecal valve at the rate o f an inch anda half in a sec ond. T he large intestine, the ureters

, and the uterus,

exhibit sim ilar waves . H . Sanders E zn,

°

l' in pursuing the same inves

tigation , places the animal in water at blo o d heat,containing 0 6 per

cent . o f comm on salt, and Opens the abdominal cavity. T he intestine inhis experiments was always at rest . After a little while slight wavym ovements o ccurred ; mechanical excitation had little effec t . Vio lentmovements o c curred when the animal was asphyxiated, but these didnot o ccur if the two vagi were previously divided in the neck . E xc itation o f the cut peripheric extrem ities induced c ontraction

,c ommenc ing,

for the m o st part, at the lower extremity o f the duodenum and the

upper end, o f the ileum . The right vagus induced the former, and theleft the latter. Sanders E zn observed antiperistaltic m o vements in o ne

case o f diarrhoea,but in all o ther cases the mo vements were peristaltic .

Dr. Dalton i states that he has arrived at the fo llowing c onc lusionsin regard to the sugar Of the l iver Sugar exists in the liver, however rap idly it may have been exam ined after remo val from the body

,

even in the living animal . (2 ) The quantity present, under these cir

cumstances,is at least two and a half parts per thousand. 3) The he

patic sugar thus found do es not pro ceed from the arterial blo od circulating through the o rgan , but is a no rmal product o f the tissue of the liver.

Gustav Strassburg § gives a mo dification o f Pettenkofer’

s test fo r thedetection o f the biliary ac ids in urine

,which he states is extremely

delicate . It c onsists in dipp ing a piece o f filtering paper into the urine,to which cane sugar has previously been added, drying it, and thendropping some c oncentrated sulphuric ac id up on it . A beautiful vio lettint appears .V. Lair and Masins apply the term stereo -bilin to a new co louring

matter obtained from the feculent c ontents o f the intestines . Its ahsorption band is prec isely limited by the lines b and F . It is so lublein water, alc oho l and chloro form ,

inso luble in sulphuric ether.

A very longpaper will be found in the ‘Comptes Rendus’ fo r May29 , 187 1 , by M . Payen

,on the substan ces used as fo o d during the

Siege o f Paris . Am ongst these blo od in the fo rm o f blo o d-puddings,horseflesh, the dried albumen o f eggs, and preserved fruits, o ccupied a

prom inent po sition .

A . Gusserow fll shows presence o f urea in liquo r amnii, and passageo f io dine from stomach of m o ther into urine o f foetus .For o ther papers see Leube, “ Weissfiy

‘Pfluger’

s Arch iv, ’ iv, 1871 , 33 .

‘

l‘ Centralb latt,

’1871 , 479 0

I In a paper read b efore the New Y ork Academy o fMedic ine, June 15, 1871 .

iv, 10 . Centralb latt,

’1871, 369.

1T Zur Lehre vom Stofi‘

wech sel des Foetus,” Arch iv fi'i r Gynaec ,

’ i ii, 24 1 .

Ueb er die E rnahrung von Kranken durch Zufuhr des E rn’

ahru ngs-materials per

anum .

’

“ Zur Statik des Glycogens im Thierko rper,”

Sitzungsb er. der W ien Akad. d.

W is senschaft, ’ lxiv, 1871 .

II Umwandlung von Bilirub in in Centralblatt,’1871, 847.

2


A series o f researches undertaken by Gustav Meyer i‘ on man and

dogs , having for their object the determination o f the relative value ofdifferent kinds of bread used in Germany, namely, rye bread (Ro ggenbro d, Miinchen) , white wheat bread (Weizen-brod, Semmel) , the Ho rsford-Liebig bread, and c o arse rye bread (Pumpern ickel) , l ed to the

result that, with equal weights o f the dry sub stance, the white wheatenbreadwas dec idedly themo st nutritious o f the four kinds o f bread, Sinceunder its use the smallest quantity o f faeces were excreted, whilst thelargest proportion ofnitrogen was extrac ted in the pro cess of digestion .

Next to the wheaten bread in nutritive value was the rye bread fernented with leaven (sour dough , Sauerteig) , but c ontaining no bran.

Then fo llowed the Horsford-Liebig bread (prepared without leaven, but

risen or made porous by the extrication o f carbonic acid from the bicarbonate o f soda and ac id pho sphate o f lime and magnesia) . And lastly,the pumpernickel . When the question o f c o st came to be co nsideredit was quite a different matter

,the white wheaten bread standing at the

bo ttom o f the list , and the Pumpernickel and Mi’

inich Roggenbro do ccupying the next place.

J . Rankef has written an important pamphlet, the general purport o fwhich is to Show that during the activity o f any o rgan , no t only is thesupply of blo od to it increased, but there i s a dim ini shed supply ofblo od to the remaining o rgans o f the body

, relations which he expressesunder the term “ functional interchange ” Funktions-wechsel andwhich have many impo rtant practical bearings .E . A . Parkesj: has made some further experiments on the effect 01

diet and disease on the elimination o f nitrogen ,and shows that when

the n itrogenous fo od o f a healthy man was reduced to one half fo r fivedays, and he was then kept for five days m o re without nitrogen, he wasable on the fourth day o f such deprivation to do a very hard da ’

S

wo rk . Non-nitrogenous diet appeared to suit him well . The p se

became so ft, but no t altered in frequency .

V . Subbo tin § maintains, in oppo s ition to Parkes, Anstie, and o ther

E nglish Observers, that when alcoho l is ingestedin c onsiderable quantity,it

d

least 16 per cent . is eliminated by the bowels,lungs, skin , and

1 neys .Dr. Dupré, “ o n the o ther hand

,shows that at leas t an ounce o f pure

alcoho l may be entirely c onsumed in the system per diem ,o r

,at least ,

that more than this quantity must be ingested befo re any materialquantity is eliminated by the urine and breath .

Paalzowfil

.

Gen .

.

Pleasanton, o f Philadelphia, has a paper on the influence ofVio let light on the growth of animals and plants .

“

9? ‘Zeitschrift fur Bio logie, ’ vii, 1871, 1—48.

1 Die Blutvertheilung und der Thatigkeitswechsel der Organe,’8vo , 1871.

1‘Proc eed. Roy . xix, 1871, 349.

Zeitschrift fur Bio logie,’ vii, 4 .

On the E lim ination of Alc oho l, Royal So c ., see Nature,’ v

, 2 74 .

HI“ Ueber den E influss der Hautreize auf den Stoffwechsel, ” ‘Pflr

'

iger’s Archiv, ’

xv, 492 .

as: ‘Academy,’ March, 1872 , 95 .


nution o r abso lute arrest o f the secretion when the system i s fully underits toxic influence .

0

Cyon and Al adoff’x‘ co rroborate E ckhard’s statemento

that diabeteso ccurs in dogs an hour after the section o f the inferio r cc ical o r

upper dorsal ganglion . They c onsider it to be a phenomenono

o f paralysiso f certain fibres passing from the spinal co rd to the gangh a, and fromthence to the ganglion stellatum through the annulus V ieussenu . Theyfind vaso -mo tor nerves fo r the liver running in the annulus V ieussenii.1°Kupressowi inserted a tube into the bladder o f o therwise uninjuredrabbits

,and tried what height o f a c o lumn o f water was required to

o vercome the resistance o f the Sphincter musc le . It amounted to40—60 centimeters . If, however, the Spina l c o lumn were divided

between the fifth and seventh lumbar vertebrae the pressure required forthe same purpo se immediately fell to 1 2—16 centimeters .M

. Decaisne§ shows from o bservations made during the siege o f

Paris that the milk o f woman has les s butter, caseine, sugar , and sal ts,but m o re albumen ,

than natural,when the diet is insuffic ient.“

Bo ll has given the histo lo gy o f the lachrym al glands in ‘Stricker’ sManual

,

’Ro l letfil that o f the gastric glands , Schwalbe" that o f the

duo denal glands , and Bo ldyrewH° that o f the laryngeal and trachea l

lands .gG . LottII finds that the uterine glands of the pig, cow,

sheep, rabbit,m ouse, and bat, are lined with ciliated epithelium .

NERVE S .

The structure o f the nerves has been specially investigated byRanvier§ § andM . Ranvier’ s researches were made upon nerves sta ined with piorocarm inate o f ammonia

,with ero smic ac id

,and with nitrate o f silver.

He states that by means o f t ese reagents he has been able to disco verthe presence of annular c onstric tions suc ceeding each o ther at the distan ce of about a twenty-fifth o f an in ch in all nerve-fibres . The c on

striction seem s to b e due to a thicken ing o f the sheath o f Schwann,and at this p o int the white substance o r medullary sheath

,but no t the

cylinder axis , is interrupted. About m idway between every two

constrictions is a nuc leus the o uter surface o f which is in contact o r is9? Bull . de l ’Acad. Imp . de St. vi ii , 90 .

1“ See a lso E ckhard, “ Untersuchungen i

'

iber Hydrurie, ” ‘Beitrage zur Anatom icund Physio logie, ’ vi, 53, and Maley, “ Kunstliche Umwandlung von Bil irub in in

Harnfarb stoife,” ‘Ko lbe’ s Journ . f. Pract. v

, 10 2 .

I‘Pfli

’

iger’s Arch iv,’ 1872 , 2 9 1 and Ccntralb latt,

’1872 , 430 . Zur Physio logic

des Blascnschliess-muskels .

”

‘Rev. 2 c sér. i, 163 .

HSee also a lecture by J . Emerson Reyno lds , On the Chem istry of Milk, ’ deliveredb efore the Royal Dub lin S o c iety, May 13, 1871 and Bogom o lofi On the Compo s itionof M ilk ,” Centralb latt,

’No . 40, 187 1 .

11'

Ro llett’s Untersuch . aus dem Institute fur Phys . ii Histo l. in i i, 143 .

‘Schultze’ s Arch iv,’ vi ii, 1 , 1 28.

Bo llett’ a 187 1, p . 2 37.

II Untersuchuiigen aus dem Institute fur Physio logic in 1871, 2 50 .

Brown-Sequard’ s ‘Archives de Physio log ie, ’ 1872 , 1 2 9.

Ill]‘Centralblatt,

’

No . 38, 1872 .

NERVE S . 21

actually fused with the sheath o f Schwann, whilst its inner surface isreceived into a kind of cup fo rmed o f the white substance of Schwann .

It would,therefore

,seem that each interannular segment represents a

cell . He finds,as Frommann and Grandry had already done before

him, that the cylinder axis under the action o f n itrate of silver presents alternately light and dark striac no t distantly resembling musculartis sue.

T amam s chefl’

excised nerve-fibres from the sciatic or brachial p lexusand m o istened them with serum . He finds that many nerve-fibresare bound together into a fasc iculus by a sheath made o f flattened cellswhich can be rendered visible by nitrate o f silver

,and which probably

belong to the lymphatic system . Shortly after rem o val from the bodythe cylinder axis breaks up into a series o f sphero idal bo dies whichhe term s c orpuscula nervea

, and which are capable o f spontaneousmovements . They equal the red co rpusc les o f the blo od in size .

Pure albumen undergo es changes o f a sim ilar nature.

E ngelmann* calls attention to certain c ontractions indicated bywrinkles in the sheaths o f nerves, but no t ac companied by Shortening,when the nerves are remo ved from a living an imal and quickly submitted to the action o f induc tion sho cks whilst lying in a weak so lution o f c ommon salt . No wrinkles are vis ible in naked axis cylinders .Rutherfo rd? has investigated the varying excitability o f the nerves

in various parts o f their course . He argues against Pfliiger’s avalanchetheory, and maintains that the excitability o f any po int in the trunkof a spinal nerve, whether afferent or efferent

,is inversely as the dis

tance o f that point from the nerve-centre .

Schlischi finds that stretching the nerves of fro gs with a weight o fforty grammes had little effect on their exc itability, but when the

weight applied was greater than this the exc itability rap idlydim ini shed.

Schifi'

has again investigated the function s o f the spinal cord as a

conducto r. He has satisfied him self that the po sterior c o lumns c onveytactile impressions . When divided, no o ther part o f the c o lumn can

supply their place, and after a few days, when the disturbing c onditionshave subsided

,tactile sensibility is entirely and permanently lo st .

Dittmar“ concludes, from his experiments on rabbits po isoned withwo orara

,that a system of fibres exists in the Spinal c o rd which, though

they do no t belong to the nerve-ro o ts,

‘

are capable o f responding to the

action of direct stimuli,and can transm it the impul ses thus generated

along the spinal c ord to the medulla oblongata, where they undergoreflection into m o to r nerves .V . Willyfil states that it is generally adm itted that the degree o f

excitation o f a nerve measured by the extent o f c ontrac tion o f the

muscle to which it is distributed augm ents with the length o f the

segment of the nerve thro ugh which the current is transm itted afterthis is clo sed o r after it is opened. He finds

,however, that this only

‘Pfluger’s Arch iv, ’ v, 1 .

Humphry and Turner’s Journal of Anat. and 1871, 329.

I Zeitschrift fiir Bio logie, ’ V l l , iv.Centralb latt,

’1872 , 774 .

H Ludwig’ s Arb eiten ,’ 1871 .

1T‘Pfli

’

iger’s Arch iv, ’ 1872 , 2 75.

22 REPORT ON PHYSIOLO GY .

ho lds go od for the descending current, whils t the converse obtains for

the ascending current.important series o f researches was undertaken by

Hitzig* on the effects o f stimul ating vario us parts of the cerebralhemispheres by means of the galvanic current . The skul l was removedwith the exception of that part covering the superio r longitudinalsinus in dogs . The irritation o f the surface o f definite regions o f limitedextent o f one hemisphere called special groups o f muscles on the

op po site side of the body into action . Thus , irritation o f one spo tduced contraction of the muscles o f the back of the nec k, ano ther theextensors and abductors o f the fore leg, ano ther the flexors and ro tato rs ,o thers the musc les o f the hind leg and o f the face . The irritation prosceeded princ ipally, if not exc lus ively, from the po sitive po le .

Heidenhain? investigated the changes o f temperature in the brainresulting from excitation o f the senso ry nerves . He compared thetemperature o f the brain with that o f the ao rtic blo od by the thermoelectric method

,and convin ced himself that the brain con stant]

po ssesses a higher temperature than arterial blo od,and that this difi

ference increases considerably on excitation o f the senso ry nerves .

There is a co incident fal l in the temperature o f the blo o d traversing theao rta, vena cava, and hepatic vein ; this fall is o c casioned in some way bythe medulla oblongata, since it do es no t o c cur if a section o f the co rd bemade just below the medulla . The fall in the temperature of the blo odis accompanied by a rise in the pressure, bo th in the arteries and in theveins, and with an augmented rapidity o f the blo od-current in bo th .

He attributes the changes in the temperature o f the blo o d to an

increased lo ss o f heat from the surface.

Schifli has continued his researches referred to in the last BiennialReport on the extrication o f heat during the functional ac tivity o f thenervous centre, and shows c learly that the augmented temperaturedepends on mo difications o f the circulation

, and is primarily due to thevaso -m o tor nerves .Dr. Franz Riegel,§ after repeating the experiment o f division o f thespinal co rd oppo site the sixth cervical vertebra and corrobo rating thefact o f the general fall in the temperature o f the body that fo llows thato peration, appears to think it may in part be due to paralysis o f thevaso -mo to r nerves leading to dilatation o f the vessels and c onsequentincreased evaporation and expo sure o f the blo od to the co o ling influenceo f the air and radiation, but that it is chiefly due to an abso lutelydiminished production o f heat, in favour o f which view he adducesvarious arguments .

Fick | | gives an account o f a series o f experiments he made on theEffects o f heating and co oling the blo od passing to the vaso -m o to r andcardiac nerve-centres, and states that, to his surprise, he o btained only

Reichert und Dub o is Reym ond’s Arch iv, ’ 1870, 300 .

f Pfli'

iger’s Arch iv, ’ iii, 504 .

81 Brown -Sequard’s ‘Arch ives de Phys io logie,’ January, March , May , and July,

1 70 .

‘Pfluger’

s Arch iv,’ No . 12 , 1872 .

Idem, v, I .

NERVE S . 23

negative results , though when such changes were induced in the blo odpas sing to the respirato ry centres very m arked effects were Observed.

Ludwig and Owsjannik o ffl"find that the vas o -mo to r centre extends inthe medulla o blongata from 1 min. under the c o rpo ra quadrigemina to4 or 5 mm . above the calamus scripto rius and on either side o f themiddle line .

For a full abstract of Ludwig and Hafiz’s paper on the vaso -mo tor

nerves of arteries distributed to musc les in Ludwig’s Arbeiten,

’1870 .

(See Brun ton’

s repo rt in ‘Humphry andTurner’ s Journal ,’ 1872 , p .

These experimenters Show that the vaso -mo to r nerves distributed tothe arteries supplying certain musc les may have a to tally distinc t o riginand course from the proper mo to r nerve o f the musc le. The bicepsfemoris, fo r example, is mo torially innervated from the sacral plexus, butits vaso -m o to r nerves are contained in the lumbar plexus and run withthe crural nerve, whence they pass to the branches o f the fem o ralartery. The vas o -mo to r nerves distributed to arteries supplying musc lesare easily exhausted, and when such arteries are expo sed to high blo odpressure they contract powerfullThe question o f trophic nerveshas been discussed by Schiefferdecker,?

Fischer,i Jo scph ,§ and Sinitzin . ”

Schiefferdecker gives the detai ls o f a series o f six cases of injury o fthe nerves o f the upper extremity . The tro phic disturbances wereatrophy o f muscles

,thickening and strong pigmentation o f the skin

,and

augmented desquamation o f the epiderm is . The finger~nails became

curved, like talons , with transverse ridges the arm c overed with hair,

and there was an excessive secretion o f sour sweat . The temperaturewas below the normal . He attributes some o f these symptoms to lesiono f certain trophic nerves, and o thers to disturbance in the distributiono f the blo od supply . Sinitzin shows that after section o f the superio rcervical ganglion of the sympathetic the conjunc tiva and choro id are

capable o f resisting an amount o f irritation to which they would o therspeedil y suc cumb . It is wo rthy o f particular no tice that Sinitzin

found the s mptoms o f impaired nutrition in the eye c onsequent uponsection o f t e fifth pair o f nerves can be altogether abrogated by subsequent ablation o f the superior cervical ganglion , a strong pro o f thatsuch alterations and lesions o f nutrition are no t the direc t result o f thenerve injury

,but dependupon impaired o rmo dified blo od supp ly. Brown

Séquardfll o bserved gangrene o f the c ar in rabbits after injuryi’o f one

co rpus restifo rme with hereditary influence on the yo un He alsoobserved pulm onary haemorrhages after injury o f one S ide O the pon s .Dr. C . Westphal corroborates M . Brown-Sequard’s statements in

regard to the artific ial production o f epileps in guinea-

p igs . He findsthat this condition may b e induced by slig t blows on the head, andattributes the convulsions to slight extravasations of blo od which hefinds in the medulla oblongata and cervical and even dorsal po rtion of

the spinal cord.

9“ Ber. d. Sachs. Gesell . der 1871, 135 .

Berlin Klin. 187 1, 160 .

Central blatt,’1871 , 72 1,

Gazette Médicale, ’ 1871 , pp . 14 and 24.


contributes a go od paper on the distribution o f the non

medullated nerve-fibres in the membrana n ictitans . He p laces theperfectly fresh membrane in a one-half per cent. so lution o f chlo ride o f

go ld fo r an hour, next cautiously transfers it to pure water, at the sametime expo sing it to a bright light fo r some days, and then brushes. o ffthe epithelium and m oun ts the Spec imen in glycerine . He describesfour o rders o f nerves, the finest, which he traces to the internal surfaceo f the capillaries and to the cells o f the ep ithelial investment, are delicately varic o se and require a No . 9 o r 10 immersion lens .Pouchet? believes he has traced the finest branches o f certain nervesinto the interio r o f the sarc odic masses fo rming the chromob lasts o f

flat fishes where they become c onnected with the nucleus and pigmentgranules . Dr . Bealei: in a paper in the same j ournal contests thisstatement .SchObl§ describes the term ination of the nerves in the wing o f the

bat, and states that some fo rm an extremely fine lexus , whilstend in tac tile c orpusc les in c lo se relation with t e hairs , the fo rmerm inister

,he thinks

,to sensations o f temperature and pain, the latter

to o rdinary tactile impressio ns .T h . E ngelmann ” gives the result of his investigations upon the innervation o f the c ontractil e gland-cells o f the fro g. He shows that theseglands can be made to c o ntract by direc t irritation

,by vario us kinds of

exc itation applied to the peripheri c extrem ity o f the divided sc iaticnerve, and also reflecto rially .

Pflugerfil sho rtly discusses the objections that have been advancedagains t his views respecting the m ode o f termination o f nerves in glands .T o Show the c orrec tness o f his statements he recommends the freshsubmaxillary gland of the ox o r sheep to be taken and fine sec tionsmade these must be at once teased out with ero smic acid sp . gr. 1 003 ,and c o vered with a thin glass in a shallow cel In the cas e o f the liversections must be made from the fresh gland and placed in watch-glas sesfilled with Beale’s carm ine so lution fo r fourteen days . E ach sec tionmust

t

tl

é

en b e washed with the above so lution of pero sm ic ac id andm oun e

Other papers on the nervous system are by G . Valentin,”Bern stein

,ii J .

NavratilfiHl MichaelQuart. Journ . of Micro sp . January, 1872 .

Month ly M icro sc op ic al Journal,’ vi, 2 85 . I Idem , vii , 45 .

‘Arch iv f. Mikro skop . Anatom ie,’ vii, 1 .

Pfliiger’s Archiv, ’ iv, 187 1 , 3 , and v, 498.

1?‘Arch iv fur Phys io logie, ’ 187 1 .

95ii “ Po s itive und Neg . Strom schwankungen als Zeichen gew iss . Zersetzungsstufender Nerv. und der Muskelmasse, ” Zeitschrift fur Bio logie,’ V i i, 1 10 .

‘Mech an ismus d . Nerveii u . Nerven Centra,’ E rlangen , 187 1 .

II T he E ffec ts o f Stimulation of Nerve and Musc le,’ 187 1, Heidelberg .

“ T hedflflfects o f E lectric S timulation of Nerve and Musc le, ” ‘W ien .Akad.

S itzungsb erich t,’ lxi i, 537 and Humphry and Turner’s Journ of 1872 , 2 23 .

Theory o f a Nervo us Atm o sphere,” ‘Med . Times and i

, 187 1 .

s

fllfig7

“ The Functions o f the Laryngeal Nerves, ” Med. Times and June1 1 2 .

“ ii The Term ination o f the Nerves in theU Bl dd f h n

tralblatt fi'

ir die Med. W iss ,

’

No .

u nary a er 0 t e Frog, Cen

SPECIAL SENSE .- TONGUE . 25

Ihldcr* finds the nerves o f the tongue in birds end in a ganglion-cell .He also describes a spec ial fo rm of bulb of ellip so idal form with a

simple connective-tissue investment and transversely placed nuclei .The nerve ends with a well-marked swelling.

R . W o lferz? arrives at the fo llowing results from his conclusions inregard to the innervation of the lachrymal glands — 1) The lachrymal isthe proper exc ito -secretory nerve o f the gland. (2 ) The subcutaneusmalae has the same but less energetic action . (3) After sec tion o f thelachrymal no reflex can be exc ited through the fifth , but readily throughthe o ptic . o f the sympathetic sometimes gives po sitive,sometimes negative results . 5) The secretion c ontinues after sectionof the lachrymal and sympathetic (paralytic secretion) . (6) Po is oningwith wo orara excites the secretion even after section o f the lachrymal

,

though less than on the Oppo site side.

Ph . Lussanai adduces fresh evidence, chiefly of a patho logical nature,in support of his views respecting the nerves m inistering to the sense o ftaste. These cases show that the lingual in man presides o ver thegustatory sensibility o f the anterior po rtion o f the tongue, fo r in a

woman in whom a portion was rem o ved by Prof. Vanzetti , sensationwas entirely abo lished

,though the form , co lour, and nutrition of the

o rgan remained unimpaired. But the lingual nerve in man is c ompo sedo f the lingual - proper and the chorda tympani, and there are cases o fcomplete paralysis o f the fifth on reco rd in which

,nevertheless, the

gustatory sense was retained. On the o ther hand, there are cases o fparalysis o f the fac ial in which gustatory sensibility is lo st, though thefifth is intact . Hence Lussana concludes that the sense o f taste in theanterior art of the tongue is due to the cho rda tympani .Dr. Sc apringer§ finds that on contracting his tensor tympani, o ver

which he has vo luntary contro l, all no tes below seventy vibrations arerendered inaudible.

Other papers on the spec ial senses are by Dr. Swan Burnett,” E .

Masch, E . Kessel,and Prof. Rudingerfl

A mo st elaborate paper, entitled E tudes d’Anatomie Comparée sur

les Organes du Toucher chez divers Mammiféres , O iseaux, Po issons etInsectes, ’ by M . Jo bert, is contained in the i 6th vo l . o f the Annales desSc iences Naturelles, 1872 .

At one o f the meetings of the Medico -Chirurgical So c iety (FebDr. W. H . Bro adbent read a paper on the mechanism of thought .

His theory was based partly on the resul ts o f dissec tion , partly on

remarkable cases o f lo ss of Speech and paralysis . He c onsiders that theimpressions derived from the several senses are conducted by fibresradiating from the crus cerebri and central ganglia to the convo lutions

Reichert und Dub o is Reym ond’s Arch iv,’ 1870 , 238. Ho nigschmied,“ V er

breitung der Bech erform igen Organe der Zunge, in Centralb latt,’ No . 2 6, 1872 .

1 Inaug. dissert ., Dorpat , 187 1 , Ab stract in ‘Centralb latt,’1871, 838.

I“ Sur les Nerfs du Gout,

” ‘Brown-Sequard’s Archives de Phys io logie, ’ 1872 ,150 and 334 .

‘W ien . Akad. lxi i and Humphry and Turner, 1871 , 40 1.

II“ On the Functions of the Co ch lea, ” in the ‘Medical and Surgical Reporter,

Nov . 4, 787 1 .

T Bewegungen des Gehororgans,”Centralblatt,

’187 1, 593.


o f the longitudinal and Sylvian margins o f the hemispheres , the intervening convo lutions receiving no radiating o r call o sal fibres . In the

fo rmer (or marginal convo lutions) impressions are reco gnised as perceptions, whilst the perceptions derived from different sources are amciated together to fo rm ideas and become the subjec ts o f thought in thelatter (o r interven ing convo lutions) N ow

, when it is desired to expressthese trains o f ideas in speech , impulses are transm itted alo ng thosemedullary fibres o f the brain that extend from the supreme centres tothe third left frontal convo lution . In this the ideas are fo rmula ted in towo rds , which are intellectual symbo ls, the centre selecting, as it were , thes ounds appropriate to the expression of the idea . T o produce the

audible expression o f these sounds that centre again in its turn propagates impulses to the co rpus striatum , the great cc -ordinating mo torcentre at the base o f the brain. In order to speak, a great variety ofmuscular m ovements have to b e cc -ordinated, as tho se o f the chest

,

larynx, tongue, and lips . The c c -ordination is effected by the co rpusstriatum, which acts upon the requisite nerve-nuclei in the medulla.o blongata . Lesions at different points o f this chain o f ganglia and

fibres will , o f c ourse, be fo llowed by different effects . The sequence ofevents on Dr. Broadbent’s theory is—the fo rmation o f perceptions in themarginal convo lutions at the summ it o f the sensory tract ; the combination of these to fo rm ideas and their employm ent in trains of thoughtin the convo lutions withdrawn from immediate relation with the o uterwo rld ; the propagation o f exc itations to the third left frontal co nvo lation, leading to the selection o f certain sound gro ups the co -o rdinationin the corp us s triatmn o f the muscular mo vements required to pro ducetho se sounds and finally

,the transmission o f impul ses from the

several nuclei o f the medulla oblongata to each individual musclerequired to be bro ught into play .

describes the fibres o f the musc les o f Trombidium , a s ccieso f red sp ider, as compo sed o f a number o f compartments fo rmed y thesarco lemma on the one hand and suc ces sive transverse septa on theo ther. From septum to septum the contents o f each compartment areas fo llows A singly and slightly refractile substance, which becomesslightly co loured with pero smic acid. (2 ) A granul ewhich stains deeplyWith pero smic acid, and with its neighbours fo rms a transverse layer ofgranules . 3) The same as (4) The doubly and strongly refractingsubstance, becom ing deeply stained excepting sometimes near its centre.

(5) As (6) As (7) As ( I) . T o which may b e addedthe deeply tinted transverse septum itself.Merkel ’s? views as regards the structure of muscle agree in many

po IHtS.

with tho se o f Flo egel . He recommends for o bservation thethorame musc les of the fly o r bee, and states that the phenomena oftheir contraction may be distinctly seen when the fibres are immersedin albumen . The appearances presented arc —first, the terminal disksapproximate the lateral expansion of the fibril s then o ccurs quitegradually, and is accompanied by a narrowing o f the part o ccupied bythe contractile substance. When the contraction is completed thead]Oinmg terminal disks are seen clo sely appro ximated the part o ccupied

‘Max Schultze’s Arch iv f. Mik. viii. 69. 1‘ Idem, 34+


E xperiments undertaken by Sczelkow,Al . S chmidt, W .

.

Sadl er, and

Genersich , in Ludwig’ s laboratory, are oppo sed to the exc lusive adoption

of either of these views, and show that great variation s may o ccur in therapidity o f the current o f blo od traversing the arteries o f

.

muscles , as_well as in its pressure, quite independently o f the condition of c on

,

trac tion o r relaxation o f tho se musc les themselves . These experimentstend to show that great powers o f contrac tion and dilatation must beattributed to the arteries distributed to musc les , and in acc ordance withthis is the anatom ical fac t that the arteries o f muscul ar tissue c on

tain a very well-developed c ircul ar muscul ar layer. Mo hammedHafiz ’ sresearches were undertaken to ascertain the c ourse and ac tion o f the

m o tor nerves supplying the arteries . Dogs and rabbits were employedin the experiments, which were either in their natural state o r po iso nedwith wo orara, and the fo llowing resul ts were o bta ined Duringtetan ic exc itation o f the spinal co rd the c ircular muscular fibres o f thearteries distributed to muscles contrac t slightly and transiently, andnever to so great an extent as the c ircul ar fibres o f the arteries distributed to the skin and abdom inal viscera . The c ontraction,

if any, isvery slight in curarized an imals . (2 ) The nerves o f the c ircularmusc les are very easily exhausted. This is well shown by the fact thata wound o f a muscle , provided no large artery is injured, as a rulebleeds but little but severe haemo rrhage o ccurs , under the same c ircumstances, if the s inal c o rd be irritated, the amount depending on the

increase of b lo o pressure caused by the stimulation o f the c o rd. T he

m o re this augments the m ore the arteries o f the skin and the abdominal viscera contract, whilst tho se o f the muscles permit free blto take place from them, the haemorrhage lasting as long as the b lo

pressure is abo ve the normal . 3) Irritation of the spina l c o rd causeddistinctly o bservable increase in the rap idity o f the current o f bloodthrough the muscular arteries , as well as by augmented pressure, cessation o f the irritation being fo llowed by dim inution o f the rapidity ofthe current . (4) The c ircul armuscular fibres o f the arteries distributedto muscles expand and c ontract independently o f the nerves supplied tothem

,and probably as a consequence o f the direc t exc itability o f their

own proper muscular fibres . (5) The nerves of a mus cl e and the

nerves of the artery supplying that musc le seem ,in some instances at

least,to have a different o rigin . (6) From a medium c ondition the

musc les o f the vessels may either c ontract o r di late ; c ontraction o fteno ccurs if the vessel has been long in a state o f dilatation, owing to augmented pressure. It was invariably observed after irritation app liedto the spinal co rd, this producing, first

,temp orary c o ntraction, then

dilatation ,and finally very strongly marked and persistent c ontrac tion .

The increase o f pressure in the arteries distributed to mus c les is, nodoubt, in part due to the contraction that o c curs in the cutaneous,abdominal , and o ther arteries, when the spinal c o rd is irritated.

Dr. Marcet Observes* that muscular tis sue is fo rmed o f three differentc lasses o f substances the first inc ludes tho se substances which c onstitutethe tissue proper, or the portion o f flesh inso luble in the preparation o fthe aqueous extract, and consisting o f albumen and pho spho ric anhy

‘Nature,’ May 18.

SPECIAL SENSE .—TONGUE . 29

dride with varying proportions o f po tash and magnesia the sec ond c lassinc ludes the same substances as are found in the tissue proper, and inthe same propo rtions relatively to the albumen present in that c lass

,

but existing in so lution and in the c o llo id state ; the third c lass inc ludesthe same substances as are found in the two o thers

,and,m o reo ver

,a small

quantity o f chlorine and soda , which , although relatively m inute, is neverabsent . The c onstituents o f this c lass are crystall o id, and c onsequentlydiffusible, the pho sphoric anhydride and po tash being present prec iselyin the pro po rtion required to fo rm a neutral tribasic pho sphate, o r a

pyropho sphate, as the fo rmula 2KOPO5 c

an equally be 2KOHOPO5 .

Dr. Marcet further believes that flesh c ontains in sto re a supply o f

nourishment equal to about one third m o re than its requirements fo rimmediate use, this being apparently a provision o f nature to allow o f

muscular exerc ise during pro longed fasting . He mainta in s that thenumbers representing the excess o f pho sphoric anhydride and po tashin blo o d o ver the proportion o f these substances in an equal vo lumeo f serum , in the regular normal nutrition o f herbivorous animals

,

appear to bear to each o ther nearly the same relation as that whichexists between the pho spho ric anhydride and po tash on their way o ut

o f muscular tissue ; and he po ints out that vegetables used as fo od fo r

man and animals,such as flour

,po tato es, and rice, transfo rm pho s

pho ric anhydride and p o tash from the crystallo id o r diflusible into thec o llo id or undiflusible state, and that it i s only after having been thusprepared that these substances appear to be fit to become normal constituents o f blo od and contribute to the nutrition o f flesh .

A final remark, and one which he c onsiders to b e worth consideration,is the fact established by the who le o f his investigation , that there is ac onstant change o f ro tation in nature from crystallo ids to co llo ids, andfrom c o llo ids to crystallo ids .Petersen

,

*as the resul t o f numerous analyses o f the flesh o f sheep ,

pigs, ho rses, and o xen ,finds that the am ount o f water varies in these

different spec ies as much as per cent . calves have the m o stper cent .) pigs the least per cent ) . The propo rtion o f nitrogenvaries but little . Thus

,the fresh muscle of o xen c ontains per cent .

of nitrogen ,that o f the pig 3 ‘

s 5 , Of the sheep o f the calf and

of the horse per cent . The propo rtions are somewhat different ifthe fat is first rem o ved

,the average fo r freshmeat

,taking all the anim als,

and the fat being remo ved,is 3 °

35 per cent . , which equals for the

dry muscle also free from fat.

Dr. H . Weisket finds that the adm inistration o f fo od po or in lime orpho sphoric ac id, for a c onsiderable period (six weeks) , to go ats producedno appreciable change in the compo sition o f the b ones , nor was theirfragility increased . The an imals , nevertheless, lo st their vigour, and itwas pro bable that if the use o f such fo od had been long c ontinuedpatho logical appearances would have been produced. On the o therhand Dr. Subb o tingt finds that the kind o f fo od adm inistered to pigeons,calves

,dogs, and man, exerc ises a c ons iderable influence on the amount

of haemoglobin c ontained in the blo od,highly album inous c ompounds

‘Zeitschrift fur Bio logie,’ viii, 166. 1" Idem, V ii, 179.

1 Idem, vii, 185 .

30 RRPoR'P ON PHYSIOLOGY .

increasing its amount, pure farinaceous and o ther Hen-nitrogenous food

diminishing it. Rabbits, on the average, have per cent . o f ha rm)globin,

well-nourished dogs per cent . , man per cent . In

anaemia and chl o ro sis it may fall as low as to per cent .Pro f. Haughtonfl‘ in his lec tures on animal mechanics, states that

according to his experiments the musc les of the arm s o f a youngaccustomed to athletic exerc ise are capable o f raism

g694

°

7 lbs . persquare inch o f their sectional area . The muscles o f the g are strongerand can lift I I o

°

4 lbs . per square inch of sectional area ; tho se o f the

abdomen 107 lbs ; he takes the mean at 1 04 lbs . A single ounce in

weight o f the muscle of the human heart will lift 2 5°

5 76 be. throughthe height o f one fo o t in a m inute.

Heidenhain,1

°

after dis cussing the views o fHarles s, Cyon, and o thers,respec ting the tone o f the vo luntary musc les , gives the results o f hisexperiments, which have led him to the conclusion that the tone of

musc les is simply the expression o f their healthy nutrition, and has no

relation with their nervous supply.

Nigetiet and HeppnerI Observe that Heidenhain long ago showedthat the pro duction o f ac id in acting mus cles augments with theirtension during contraction . They made experiments to determ inewhether the same ho lds go od fo r the o ther compo unds resul ting fromthe metamo rpho sis o f muscular tis sue

,and, ado ting Helmho ltz and

Ranke’s m ode o f pro cedure, that is, comparing t e alco ho lic with thewatery extract (the latter decreasing, the fo rmer increas ing, duringthe period of activity) , they found that in mus cles under o therwise precisely sim ilar c ircumstances, but o f which one was weighted whil st theo ther was no t, the fo rmer yielded mo re alcoho lic and less watery extractthan the o ther .Dr . A . Héno cque§ states the nerves supplying smo o th muscular tissue

are distributed in three plexuses a basal or fundamental plexu s,containing numerous ganglia situa ted externally to the muscle ; (2 ) anintermediate plexus and (3) an intra muscular plexus

,situated in the

interior of the fasc iculi o f smo o th fibres . The term inal fibres are everywhere alike, dividing dicho tomous ly, and ending with a slight enlargement o r button, or in a punctifo rm manner. These swellings are situatedin different parts of the smo o th muscle, o ften near the nuc leus , or on thesurface, or between the fibres .M . A . Sawicki ” shows that the quantity o f uric ac id excreted by thekidney is in relation with the fo od rather than with the amount o fexercise taken .

Dr. W. Oglefll shows that bo th the right leg and right arm are usedpreferentially by many animals as well as by man

, and in man befo re anyeducation is commenced. From various o bservations made on rightand left-handed individuals he has arrived at the conc lusion that, likethe faculties concerned in speech, tho se asso ciatedwith the predominance

a

glib Med

gourna

’ May and June, 1871.iiger

’

s ch iv iv—x. Idem, iiiBrown -Sequard’

s Arch ives, ’ 1870, 397.I 574

Pfli’

iger’s Arch iv,’ 1872 , vi .

1 Proceed. of Roy.Med. and Chir. vi, No . 8.

SPECIAL am en—TONGUE .

of the right hand and leg are due to structural peculiarities whichare lo cated in the left hemisphere o f the brain . The greater development of the left hem isphere he attributes to its receiving a freer supp lyof blo od than the right?Oser and Schlesingefi ? state, as the essential resul t of their experi

ments, that mo vements o f the uterus may b e induced by arrest o f therespiration , by rapid haem orrhage, and by arrest of the pas sage of theblood to the brain . They found that the best animals for the purposeof experiment were kittens under the influence o f wo orara.

shows that themuscles of the embryo po ssess their true andnormal currents with negative variation on contraction long befo re theirdevelo pment is c omp lete, and so also nerves, which asyet do not appearto po ssess a medullar

y]r sheath, po ssess the power of transmitting moto r

Mpulses , and also ex ibit their normal electric currents and negativevariation during activity .

Hermanni finds that living musc le o ffers very much eater resistanceto an elec tric current passing in a direction acro ss the bres than to onetransmitted along them

,the proportion being as 7 to I in the nerves

it is as 5 to I .

Hugo Kronecker, “ On the Laws o f Muscular E xhaustion, in the

Monatsberichte d. k . p . Akad. d. Wissenschaften zu Berl in,’ 1870 .

Fick§ On the Change in the E lasticity o fMuscle during Contraction.

”

An important c ontribution to our knowledge of the physiologiceffects o f severe and pro tracted muscular exerc ise, espec ially in regardto its influence on the excretion o f n itrogen , has been made by Dr .Austin Flint, | as the result of his analysis o f the fo od consumed andurine passed Mr . Weston, during a remarkable attempt which this

pedestrian mad

}; to walk 400 m iles in five c onsecutive days . Al though

e did no t accomplish this task, he suc ceeded in walking 3 175 m iles inthat space of time. By the aid of several em inent physicians andsc ientific men o f New Y ork, Mr .Weston was subjec ted to mo st carefulobservation for five days before the walk, for the fiye days o f the walk,and fo r five days after the walk, and the results are given in a seriesof carefully prepared tables . The general conc lusions o f Dr . Flint ’sinquiry, in this case at leas t , are decidedly oppo sed to the o bservationsof Fisk andWislicenus and many m o dern experimenters, whilst theycorro borate the o ld view of Liebig that the elimination of nitro gen is toa great extent a measure of the waste of the nitrogenized elements ofthe tissues, and that this is increased by exercise.“Prof. Humphry’s** lectures, and stillmo re recently ub lished treatise

on myo lo contains the results of many careful'

ssections of themuscles gfy the Crypto branchus Japonicus, the Uromastix3“ Stricker’s Med. Jahrb iicher, ’ 1872 , 30 .

1° Histo logical Researches, ” Zeitschrift fiirBio logie,’ vii, 1871, 105.I Pfli

’

iger’

s Arch iv, ’ part vi , 1872 .

Ueb er die Aenderung der E lasticitat des Muskels wahrend gler Zuckung,‘Pfluger

’s Archiv,’ 1871, 30 1 .

Pamph let reprinted from the New Y orkMed. Journ.

’for June, 1871, 91.

WT See an ab stract in Amer. Journ, of Med. Jeu., 1872 .i"? British Med. Journ ,

’1872 .

32 REPORT ON PHYSIOLOGY .

Lepido siren annectens, Dog-fish , Cerato dus, and Pseudopus, with an

able expo sition of the general relations and arrangements o f the musclesin vertebrate animals .Franz Hofl

'

man * discusses and answers affirmati vely the questionwhether fat supp lied in the fo od enters direc tly into the fat-cells , to b esto red up in them .

The fo llowing references to various papers that were analysed forthis Report , but which were exc luded by the lim ited Space accorded toit,may, perhaps, prove useful to some readers .

HI STOLOGY .

Bizzo zero , Beitrage zur Kenntnis s der sogenannten endogenen

Zellenbildung. f—Gr’ . V . C iaccio , Nno ve Richerche sul l’

interna tess i.tura dei Tendini . ’ Bo logna, 1872 . Pamphlet . —Dr. M . Lipsky, Ueberdie entziindlichen V eranderungen des E p ithels derHarn-kanalchen .

”

1Dr.Adickes, “ Zur Histo logie des Bindegewebes .

”Inaug. Dissert . ,

1872 .

—Ranvier, “ Des E lements Cell ulaires des Tendo ns et du Tis suec onj onctif lache (tissue cell ul aire) .

—Bo ll Untersuchungen uberden Bau und die E ntwickelung der Gewebe .

—Mitchell Bruce , “ On

the Structure o f T endon .

”

flT—MM . Philipeaux et A . Vulp ian ,

“ Sur

le mode d’

accro issement des o s —Dr. Stretzofl‘

, Beitrage zur

normalen Kn o chenbildung.

”

1°

t—Dr.Heitzmann,Studien am Kno chen

und Kno rpel . ” 11 —Dr. W . Flemm ing, U eber Bildung . und Riickbil

dung der Fettzelle U eber die Anfangeder Speichel-gange in den Alveo len den —E . Kyb er,Untersuchungen iiber den Lymphatischen Apparat .in der Milz

,

’ vi ii,

568 .—Dr. Dudukalofl

'

,Beitrage zur Kenntnis s des V erwach sungs

pro cesses unterbundener Gefasse .

”

1H[—Dr.Durante , Untersuchungeniiber die Organisatio n des Throzur Kenntnis s des feineren BaueN -Th . E imer

,

Haut der Kuhzitze .

”

111—J . Sc-E . Rindfleisch,

“ Zur Kenntnis s

gung in den —A. K . v . Ajtai, E in

n iss der Geschmacksorgane . 1mfil—Dr. E . E linfeineren Nerven der Mundh ohlenschleimhaut.

“ U eber den fein . Bau und die E ntwickelung desaugethiere und des Men schen . fi H—Dr. Nuel,ness der Séiugethier schnecke.

”

111it Der Uebergang von Nahrungsfett in die Zellen des Thierko rpers ,” Zeits chrift

f. Bio logie,’ vii i, I 53 . f Stricker’ s Jahrb i'icher, ’ 1872 , 160 .

1 In idem , 55 . Brown-Sequard’s‘Arch ives de Phys io logie, ’ 1869, 47 1 .

Max S chultze’s Arch iv. furMicro sc op . vii, 2 75 .

fl" Quarterly Journal of Micro scop . Sc ience,’ April , 1872 .

Brown-Sequard’ s ‘Arch ives de Phys io logie, ’ 1870 , 53 1 .

H‘ Centralb latt,’1872 , 449. 11 Stricker’s Jahrbucher,’ i i , 339.

Schultze’s Arch iv, ’ vii, 187 1 , 3 2 . ll” Idem , vi ii, 48 1 .

flfi l'

‘Stricker’ s ‘Med. Jahrb 1872 , 1 50 . In idem , 14 3.

‘S chulto

z’

e’s Archiv, viii, 618. III Idem , viii, 643 .

Idem, vu i, 295 . “II” Idem , viii , 453 . 1T1Hl'

Idem , vi ii , 465 .

“ M Idem, vii, 1871 , 382 . HH Idem , viii, 145 . 1111 Idem , viii, 2 00 .

REPORT ON PRACTICAL MEDICINE .

*

A. B . SHE PHE RD,M .A ,

M .E . ,

ASSISTANT -PHY SICIAN T O ST . MARY’S HOSPITAL, E TC .

A. DI SEASE S OF THE GENE RAL SY ST EM .

Infl amma tion and Supp ura tion .

IN the c ourse o f the past two years the Vienna s cho o l seem s almo stto have m ono po lised the subjec t o f inflammation . Heiberg W ien .

Med. 187 1 , 7) has made numero us experiments o n the pro cesswhich takes plac e in the regeneration o f the epithelium o f the c o rnea in

frogs , fowls , and white rats . He finds,after s craping o ff the epithelium

‘"

from the centre o f the c o rnea with a kn ife , that the pro ces s o f new

growth is c omp lete in three days , and sometimes,in birds and mammals,

even earlier. From the o bservations o f Stricker and No rris,tho se

"writers had already c ome to the c onc lus ion that, in the inflamed c o rnea

'

Of the frog, the c o rpusc les m ight be transfo rmed during the inflamma

to ry pro cess into am oebo id cells . Hansen (ih .,2 1 2 ) carried o ut the

same experiments on the c o rnea o f rabbits and cats,andfinds that hand

in -handwith the appearance o f yo ung cells the c orneal c o rpuscles changetheir fo rm

,and at last entirely disappear, while their nuc lei undergo

divisio n .

Carmalt and Stricker (ih .

, 42 8) set up inflammatio n in the cornea o f

frogs and rabbits by pas s ing a s tring thro ugh the centre Of the c ornea

and thro ugh the s c lero tic , a nd give the resul ts of their o bservatio nson the fo rmation o f the blo od-ves sels , which in the fo rmer an imals to o kplace in from thirteen to fifteen days

,and in the latter from five to eight,

after the string was intro duced.

Genersich (ih .

,i) thinks , from his experiments

,that the s o -called

fixed c o rneal c ells c o rrespond to true Spaces , which c ommunicate bybranc hing canals

,and in which the wandering cells c an m o ve .

Durante’ s experiments (ih . , 3 2 1) were made in reference to ( I ) thethe change takingpro cess o f acute in

relation between the inner tunic and

‘o

In a large numb er of cases I have b een c ompelled to om it ab stracts o f papers .

h ave preserved tho se o f fo reign origin, and have inc luded tho s em ay b e m o st eas ily referred to in the b ib liography at the end of

ss s tated otherw ise, the referenc es are to vo lum es and pages . An the last report w ill b e fo und at the end of th is—A. B . S .

6

34! REPORT ON PRACT ICAL MEDICINE .

the blo od in ligatured po rtions o f vein . He findslium

,the musc le-cells

,and the c o nnec tive-tis sue c o rp

in the pro liferation which o c curs in inflammatio nvein ; and in referen ce to the

p o rtion remained fluid as lo nglium ,

but c oagul ated immediately the latter became inflamed.

Samuel has made numero us experiments into the resul tsby the injection o f various secretions , &c . A reference to h '

will be found below .

G ilterb o ck Arch . f. Klin . xiii, 2 40) an swers themade by Gussenbauer (ih . ,

xii, 81 1 ) o n his fo rmer wo rkthe more delicate pro cesses which take p lac e in the healingin the c o rnea by primary intention .

Bizzo zero Gaz . Med. Ital .fac t

,already o bserved by Buhl , Remak ,

espec ially when it has been taken from

has found large cells containing red blo o d-c ells .

Duva l Arch . d. 1872 , iv, 168) stro ngly op o ses Cviews as to the o rigin o f pus . He ho lds that the p esmatithe c o rnea do no t remain fixed

,b ut undergo hypertro phy and

tion ,and that the appearances o f c ells having pas sed thro ugh

ves sels in the -mesentery is due to the m echan ical rupture o f lym

phatic sac s in the o peration o f withdrawing the membrane from the

abdomen .

N o rris (‘Pro c . Roy . xiv, 556) c onc ludes—I . Bo th white and

red c o rpusc les pass o ut o f the vessels thro ugh apertures , which can

neither be seen befo re their ingres s into , o r after their egres s from,

the vessel-wall, but only during the perio d o f trans it . 2 . An essentially primary step in the pro ces s is that the c o rpusc les shall adhere, o r,m o re properly, co here, to the wall o f the ves sel . 3 . These co heringc orpusc les shall subsequentlv be subjec ted to pres sure from within .

V. Mo sengeil,“ Beob achtungen uber Ortliche Warme-E ntwickelung bei Entzun

dungen,” ‘Arch . f . Klin. Ch ir.

’xiii, 70 . Samuel, “ Die Sub cutane W irkung der

Secrete,” ‘Centralb l 187 1 . 433 . Id Die Ortliche W irkung des E iters und der

putriden Sto ife,”ih ., 30 5 . Id ., Putrides Gift in den Sputis , ih . 43 5 . Id .,

“ DieLo calisirung der E utzundungen, ib . , 692 . Guterbo ck .

“ Untersuchungen uber°

Sehnenentzundung,” Wien . Med . Jahrb .

, 187 1, 2 2 . Lang , Untersuchungen uber dieersten Stadien der Kno chenentzuudung,

"ib ., 34 . Huto b , Untersuchungen uber

KnOrpelentzundung, ih. , 399 . Y eo , Untersuchungen iiber die Struc tur entzundeterLvmphdriiseu,

”ib ., 30 . Pars on s,

“ Catarrhal Inflamm ation,

” ‘Brit. Med.

187 1, 1, 4 73 . Flemm ing,

“ Ueber V eranderungen dcr Fettzelle b ei Atro ph ie undE ntzundung,

” ‘V irch . lii, 568. Bizzo zero , “ Saggio di Studio sulla c o sidettaendogenes i del Pus, ” Gaz . Med. 187 2 , 33 Mays, The Path o lo gy o f Inflamm ation,

” ‘New Y ork Med. J xvi, 1 5 5 .

36 RE PORT ON PRACTICAL MEDICINE .

Lastly, there is a c lass , the subjec t o f his present paper, which comprehends the p o isonous affec tions , distinguished from the preceding by

the fact that their intimate cause is to be fo und only in the granularpro to plasm o f the new fo rmations .

Sanders o n (‘Thirteenth Rep . Med. Off. Privy app . p . 48, and

Quart . Journ . o f Micr. Sc ience ,’ xi, as s is ted by Ferrier, hasfurther investigated the c ondition s under w

is no developmenta l c o nnection between the two,and their apparent

a s so c iation is one o f mere j uxtapo sition . If pro per precautio ns , bo ilingthe so lution , 3 . g. Pasteur’s , and rinsing the ves sel with bo iling water,are taken , the so lution may be expo sed fo r a length o f time in an Open

ves sel, without any develo pment in it o f bacteria , while there will o cc ura free growth o f penic illium . If a dro p o f o rdinary distilled water beadded to the so lution used

,bac teria will be develo ped in abundanc e );

b ut such develo pment wil l no t fo llow if the dis tilled water be previously bo iled .

T he same writer Nature,’ 1873 , Jan . 9) relates m inutely fifteenexperiments made in his presence by Bas tian with infus ions o f hay andturn ip. He is c ontent to have established, at all events

,to his o wn

satisfaction ,

“that by fo llowing Bastian

’s direc tio n s , infusio ns can beprepared wh

m inutes , o f

are c harac terised by the presence o f

develo pment o f these o rganism s c an pro ceed with the greatest activin hermetic ally sealed glas s ves sels from which almo s t the who lethe air has been expelled by bo iling.

Lo sto rfer Wien .Med . J 187 1 , 45 I) has develo ped o rganis

resembling sarc ina ventriculi from the blo od o f several healthy pers oHe ins ists that they are n o t introduced from

to suppo rt his view by reference to cases rec o rded by VZenker, and Cohnheim

,as to the o ccurrence o f sarcm ae

lungs .

Ferrier Brit . Med. Journ ,

’1872 , i, 98) has found sarcinaa

blo o d o f man, rabbits

, cats,dogs , and frogs , drawn from the

vessels , and placed under a temperature o f 100° F .

Lo sto rfer as to the presence o f numero us refractiveo r in pairs , from which sarc inae are developed ; and

to be identic al .

sarcinee, as Ferrier is d

a s a living o rganism .

rence seem s to be theit is to form .

Nepveu Gaz . Med.

CONTAGION AND INFE CTION . 37

E hrenb .) in the blo od o fvfour patients affected with erysipelas, and

remarks o n the diffus ion o f the po is o n .

Bennet (J . Henry) illustrates , from his own personal histo ry187 1 , 11, 5 the fact s tated by Paget, that po is onous fluids can exert

their influence o n the bo dy by imbibition thro ugh the skin witho ut anybreach o f c ontinuity . On several o c cas ion s the po ison ,

from p o stmo rtem and uterine exam ination s

,seemed to ‘

pas s down a hair into a

hair-bulb ; at any rate,a hair was always in the c entre Of the painful

spo t . E rysipelas o f the arm and chest fo llowed, with cons iderable c on

stitutional disturbanc e .

In a lec ture o n Dust and Disease Brit. Med. J 187 1 , i ,Tyndall

,after some experiments and o bservations o n the p o lari

sation o f light by fine dust, by the sky and the c o arser partic les o f

smoke,referred to the theo ry as to the para s itic character Of c o ntagio us

disease. He believes strongly in the use o f a res pirato r in infec tio usplaces . In one c on s tructed fo r him the air enters the mo uth thro ughco tton wo o l

,and by a light valve, which is lifted by respiration ,

the

expired breath pass ing o ut by a sec o nd valve .

Liveing (‘Brit . Med. Journ

,

’187 1 , 11, 365 ) h o lds that the po is on of

c ontagious diseases is an o rgan ised po is on , each o rganic partic le o f

which must have a definite perio d o f existence, and then die a natura ldeath

,o nly able to pro pagate its spec ies during a c omparatively sho rt

period o f its existence. Allowing the difficulty o f pro ving the sam e fo r

the malarial po ison ,be yet thinks that its vegetable o rigin i s shown by

the facts o f the lo calisation o f this po ison to c ertain dis tricts , o f theneces sary c o nditio n o f a certain elevation o f temperature fo r its develo pment

,and o f the apparent inc ompatibility Of its c o existence with

the central part o f well-p o pulated towns . It seem s as if the c ongre

gating together o f inhabited ho uses effectually exc ludes the virus . He

illustrates this statement from Rome . Here the c entral part o f thec ity is perfectly free , at all seasons o f the year

,from m alarial po iso n

,

tho ugh it abounds in a c oncentrated fo rm alm o st within a sto ne’ s throwo f tho se spo ts which are perfectly healthy .

E imer, Ueb er die E i Oder Kugelfo rmigen sogenannten Pso ro sperm ien derW irb elth iere, E in Beitrag zur Entwickelungs

-

geschic lite der Gregarinen und zur Kenntn issdieser Parasiten als Krankheitsursache, ” Wurzburg . Bastian, E pidem ic and Spec ificContagio us Diseases, ’ Brit. Med. J 187 1 , i i , 400 . Id.

, TheModes of Origin o fLowes t Organ ism s inc luding a Discuss ion o f the E xperiments o f M . Pasteur, and a

reply to som e statem ents by Profes so rs Huxley and Tyndall, ” Londo n and New Y o rk ,


Ino culability of Tuberc le . T uberculo s is .

7

Paraskeva and Zallonis G az . 1872, 197) give the resultsfive experim ents o n rabbits

,which c o nfirm V illem in

’

s researches . Tb ercular matter m ixed with the fo o d, o r in o c ulated, pro voked depo sitsthe same kind in the lungs . In a sixth ex

was suffering from gangrene o f the great to f the femo ral artery , they ino culated himthe upper part o f his thigh . He diedtuberc les were dis co vered in his lungs andthe no tes of these“tuberc les ” are fo

Bifli andVergaGaz . Med. Lomb .

Milan,in o culated t

o ther animals three m onths after the o peration ,

tuberc le was found in either o f them . Sangalli seems to havethe same negative results in his experiments on twelve m ice .

Pap illon, N ico l, and Laveran Rec herches expérimen

l’

ino culation de la tuberculo se,

”Gas . des 187 1 , 342 )

peated the experiments o f Co hnheim andFrankel on rabbits an

spec ific nature o f tuberc le . Cheesy matter is in all the'

think, the first starting-po int o f the genera l tuberculos is .

glands in the neighbourho o d o f the o riginal wo und were alto undergo the cheesy change . They have never been aban eruption o f tubercles o n sero us membranes .Bogo lowsky Beitrag zur Impfung mit tuberkulOSen Massen

,

”

187 1 , 97) made parallel experiments o n rabbits with so

c alled tuberculous pus , cheesy matter, and miliary tuberc le. Bo th setshad symptoms o f fever : the latter ceased after a few days in tho seinoculated with po isoned serum ; in the rest symptoms o f inflammatio nfo llowed, resulting generally in death . The m o st frequent appearancesfound were purulent bronchitis

,with c ircum scribed purulent depo s its in

the lungs , and sometimes in the liver.

Crisp Path . So c . Tran s ,

’

xxiii, 3 1 2 ) vac c inated eightand subsequently ino culated them with smallpo x matter.

in the course o f the year,and presented

,po st-mo rtem ,

theo f general tuberculo sis .Go o dhart

’

s experiments E din . xvn , 305 ) onand rabbits do no t add much to what has already been 8

ino culatio n Of tuberc le by fo rmer Observers . N o r dorec orded as o c curring in the human subjec t

TEMPE RATURE AND FEVER . 39

The eleventh case,that o f a man who se affec tion Seems to have been

pro bably phthis is ex haem optysi, is imperfec t . Y et the au tho r reliesupo n this c ase as a typical examp le o f a c las s m ade up o f all c ases o f

acute tuberc ulo s is,where no existing cause in the Shape o f pus can b e

disco vered.

”

He thinks that al l chro nic pneumonic changes c o nsist inpart o f adeno id fo rmation .

Birch-Hirs chfeld Arch . d. xii, 50 1) rec o rds eight cases o f

miliary tuberculo s is o ccurring after typho id fever, with a full des criptio no f the m icro sc o pical appearances fo und ; and ano ther c ase o f the same

affection (ib . 5 56) fo llowing ep ididym itis in a s o ldier aged 2 4 .

Mandl , Du Tubercule c omparé a quelques autres Pro duits ath o logiques ,” Bull .

de l’

Acad. de xxxv, 82 3 . Fo ns sagrives , Du rOle de l’Elém ent inflamm ato ire

dans le Productio n des Tub ercules pulm ona ires , ih . 82 7 . Klein ,

“ Quelques Co ns iderations sur la Tub erculo se, ” These de S trasb ourg, 1870 . Moxon, Inflammation‘

and Tuberc le, ” Med. Tim es and 187 1 , i, 64 and 153 .

Temp era ture and Fever .

Pilz Jahrb . f. iv, 4 14) finds that the temperatures taken

in the rec tum o f healthy ch ildren alm o s t c onfirm the fact fo und also inadults : that the temperature rises from the first ho urs o f the m orningtowards n o o n

,reaches its highest in the first ho urs o f the afterno on ,

and then in the evening begin s to s ink again . As a rule the elevatio nis no t c ontinuous but interrupted. The greatest ris e o c curs in the

hours from 7 to 8, o r even up to 9 a m . T he fall o f the temperaturebegins as Finlayso n had already shown (see last ‘Bien . almo s ta lwa ys at six

,seldom at seven in the evening. This fall is generally

mo re sudden than in adults ; the difference in temperature amountsin the first hour sometimes to I

°

IO

. The night temperatures , whichare inc omplete , agree with tho se given by Fin layson .

Manas sein Pfliiger’

s Archiv,

’ iv,2 83 ) subjec ted rabbits to swinging,

the swing making from twenty -eight to thirty double vibrations in theminute . In all c ases the temperature fell : its maximum fall being C .

,

its m inimum 0°

3°C .

, and its mean 0 6 6°C . The effect was distinc t in

fifteen m inutes,and lasted from half an hour to two hours . The

tendency to sleep was very marked. T he animals were c lo sely envelo pedin wo o l before swinging, to prevent any fallacy in the experiment o f

mere depres s ion o f temperature from renewa l o f the air ; parallel experiments with and without wo o l are given . As a m o re pi actic al experiment he injected decompo s ingmatter into rabbits , thus caus ing pyrexia,and by swinging them afterwards, reduced their temperature even to

the normal degree .

From experiments made on 1 74 different an imals the same writerCentralb l . 187 1 , 689) c on c ludes that c ircum stances that in crease thetemperature o f the bo dy dim inish the size o f the red blo od cells, asfo r instance septicaem ic p o ison ing, expo sure to a high temperature, o rinc lo sure In a spac e surcharged with carbonic ac id ; while o n the o therhand breathing o xygen ,

expo sure o f the who le body to c o ld, theadmin istration o f hydro chlo rate o f quinine

,hydro cyanic ac id, and

alc oho l, which lower the temperature, cause also an increase in the size

40 REPORT ON PRACTICAL MEDICINE .

o f the red c ells . Hydro ch lo rate o f m o rphia fo rm ed an exc eptio n ,caus ing

dim inution o f temperature, and o f the s ize o f thered ce lls . Th is is to beexplained pro bably by the inhib ito ry influen ce thi s drug exerts o n the

respiration (c arbo nic ac id po is on ing) .

. Las tly, acute anaem ia (blo o dletting from an artery) c auses increase In the s ize Of the cells .

In a m o re or less po pular paper on the E ffec t Of E xerc ise upon theB odily Temperature

” Alpine 187 1 , May) , Allbutt thinksthat in his own case two depres s ions o f temperature

—o ne during a

descent, the o ther during a gentle ascent Of lower slo pes—were due tolack o f fuel . He thinks that with a full and as s im ilating stomach , go o dheart and lungs , a warm -blo o ded anima l is no t liable to lo se the balanceo f his fo rces during who les ome exertion . He thinks that the therm ometer is the best tes t o f the latter in different perso ns . From his own

case he c onc ludes that hard exerc ise in a m ountain o us distric t ac c elerates the m o rning rise, carrying it °

2°o r 3

°abo ve the average level o f

health ; that it als o favours an earlier o ccurrence o f the even ing fa ll, ifthe exertion be ended, carrying it °

1°

o r, perhaps , °

2° below usual

night level ; and that any depression during exertion sign ifies eitherdefic iency Of fo o d o r ineffic iency o f internal wo rk (and see Pro c .

Roy . xix,

Mign o t L’

abais sment de la temperature c omme signe de m o rt ;Gaz . 187 1 , after remarking that Labo rde had assertedthat the temperature during life never fell below 30

°

C . (86°

a llowshis o bservation to be right a s far as it has reference to adults . T he

researches o f Roger, Hervieux and Migno t him self, Show that in newlyb o rn children ,

whether affec ted o r no t with sc lerema,death was pre

c eded by a period o f gradually inc reas ing depres s io n o f temperature,the thermometer descending s ometimes as low as 2 3

°C . He

c o nc ludes that a depres s ion o f 5° below the n o rma l carries with it a fatal

pro gno s is . He thinks that the fac t may b e useful in determ ining death,and suggests that a line sho uld be marked o n thermometers m ade o n

purpo se , at 30°and and that no certificate o f death should be

given till the axillary temperature has been pro ved to have fallen as

low as the first number in adults and the sec ond in the newly born .

Liebermeister, Virchow, and Senato r indulge in a discus sio n o n tem

perature and the means o f regulating it the referenc es to their papersmay b e found below .

Pudzinowitsch 187 1 , 2 1 1) gives the results o f twelveexperiments on the relation o f the cutaneo us persp iration to temperaturein febrile c ondition s

,witho ut any certain c onc lus ions .

V ergely Gaz . 187 1 , 489) gives a case o f inten seheadache, ac c ompan ied by elevatio n Of temperature . A girl , aged 2 1

,

had c omplained fo r two o r three m onths o f pain in the head, attackingher at first at intervals , but c onstant for several days befo re her admission into ho spital . The who le head was affec ted

,but espec ially the

supra-o rbital and tempo ral regions . She c omplained also o f pain in the

lumbar region . Her pulse was 90 ; b ut there was no thing abno rmalIn her general state o therw ise . T he temperature during the first fivedays reached 39 8° C . F .) and 40

°C . ( 104

°F ) , andwas ac c om

panied by irregular and frequent pulse . On the c essation o f the head

TEMPERATURE AND FEVER . 41

ache after seventeen days , the m o rn ing temperature was 35 4°

(95 7° F . and the even ing 3 7 2 ° (98 9° F . His remarks on the c ause

o f the elevatio n o f temperature are s c arcely prec ise .

Murchison,writing o n the “

period o f incubation o f typhus , relaps ingfev ,

er and enteric fever ” St. Thom . Ho sp . Rep .

’ ii,2 3) c onc lu l es that ,

1 , the perio d o f incubation o f typhus varies in diiration in differen tca ses, in a large pro po rtion o f them being abo ut twelve days , rarely, ifever, exceeding three weeks , and o c cas ionally being entirely ab sent

,the

symptom s in the last case c ommenc ing alm o st at the in stant o f expo

sure to the po ison ; that, 2 , the perio d o f incubation o f relap s ing feveris m o re variable, arid, o n the who le, sho rter than that o f typhus , a latentperiod also no t o c curring in s ome cases ; that, 3 , the perio d o f incubatio no f enteric fever is m o st c omm only about two weeks

,though it may be les s ,

no t exceeding one o r two days . He suggests that the perio d o f ineu

bation may vary ac c o rding as the po ison is intro duced by the alimentarycanal o r by the lungs .

Begbie Edin . J xviii, 2 49) calls attention to the swelled lego f fevers . ” He firs t sketches the histo ry o f the affection from its earliestno tice by Burke and Cheyne

,in 182 1

,to the present time, and shows

that a swelling o f the lower extrem ity different from o rdinary oedema

or anasarca has been rec ognised by various writers as o c curring inthe advan ced s tages o f typhus and typho id fevers . It has never beendescribed as a sequela o f relaps ing fever. Fro m a general view o f cases

rec o rded by o thers , and tho se o bserved by him self,he c onsiders him self

warranted in c las s ifying them as fo llows — 1,cases dependent o n vas

o nlar o b struction (a) veno us o r (b) lymphatic 2,c ases in which in

flammation o f the areo lar tis sue exis ts . He gives sho rtly cases in illustration o f these three varieties

,and refers 1n c o nc lus ion to the treat

m en t, which c on s is ts in rest,bandaging, ano dyne fomentation s , the ap

p lic ation o f leeches , a genera l dietetic regulation, and the carefulwatching o f any c o mplications which may arise .

Lieberm eister, “ Zur Lehre von der Warmeregulirung ,

” ‘V irch . 111, 123 .

Virch ow ,

“ W irkung ka lter Bader und Warm eregul irung , ib . , ih . , 133 . Lieb erm eister, W irkung kalter Bader 1) E in Brief an den Herausgeber ; (2 )

“ Ant

w o rt des Herausgebers ,” ib . , ib ., 43 2 . Senato r, Kritis ches uber die Lehre von der

Warm eregulirung,”ih . , l iii, 1 1 1 . Lieb erm eister, “ Nochm als zur Lehre vo n der

Warm eregul irung ,”ib . , ih . , 434 . Id “ Untersuchungen uber die quantitativen

V eranderungen der Koh lensaure-

productio n b eim Mensch en (second art ic le), Deut.

viii , 1 53 . Silujanofl'

,

“ Zur Fieb erlehre (E xperim ents o n the changes in

quantity o f Carb o n ic Ac id, N itrogen , and Chlorine, in artific ially induc ed‘V irch . lii, 3 2 7 . Manassein,

“ Chem ische Beitrage zur Fieb erlehre,” Cen

tral bl . 187 1 , 85 2 . Decaisne,“ De la T emperature chez l 'E nfant Malade, ” ‘Gaz .

Med . , 187 1 , 197 . Hawkes , “ Ob servatio ns o n the Temperature o f the Insane,”

‘Lancet, ’ 1872 , i, 4 2 9. Dem arquay, “ Modifications imprim ées a la TempératureAn1m ale par les grands Traum atism es,” ‘Gaz . des 187 1 , p . 3 73 . B edard,

De l’Abaissement de la T em perature dans les grands Traumatismes par Armes a

Feu,

” Arch . 1872 , i , 2 9 , and Gaz . des 1872 , 33 . B ourneville, Abais sem ent de la T emperature rectal e chez un Homm e expo sé au fro id extérieur, ” Gaz .

Med 1872 , 8, and‘Gaz . des 1872 , 34 . Peter, Des T emperatures élevées

excess ives dans les Ma ladies, ” Gaz . 1872 , ix, p . 54 , 84 (and see c orrespo nd

ence b etween him and Jac c oud, ih . , Riegel, Ueb er den E influss der Curare auf

die Ko rpertemperatur,”

187 1 , 40 2 . Senator, Ueber W arm eb ildungund Stofiwech sel im gesunden und fieberhaften Zustande, ” ih ., 737. Gatzuck ,

“ Ueber


den Einfluss der Blutentleerung auf die Circulation und die Tempera tur des Korpers, ”ih . , 833 . Ogle, On the Tem p erature in c erta inbut espec ially in Tetanus ; w ith Ob servatio ns andupo n the Tempera ture of the Body, ” ‘Clin . So

On the Mo dific ationsapp licatio n o f Co ld and

th e Body ,” ‘Brit. Med . 187 1, i, 2 7 1, 8150. Bra dley, “ Efi ec t o f Ro cki ng o n

Temperature, ib . ,ii, 72 5 . Squire, “ Ob servatio ns on the Temperature o f the Body

in Health and Diseas e,” ih . i, 3 2 . W ilks , T he Use and Abuse o f the term Fever,‘Lanc et,’ 187 1 , i , 10 . Jessett,

“ Co ld Wate r Treatm ent o f Fevers , ” ib . , ii, 65 5 .

W internitz, “ Der E influss vo n Wa rmeentziehungen auf die Warme productio n,

W ien. Med. 187 1, 180 , and‘W ien . Med . 187 1 , 1 70 .

Infection from P o is on of Anima ls .

Terry, Wa sp-stings (two c ases, o ne of a lady stung in the m outh , the o ther swell

Ing o f a leg from fo o t to knee, from st ing in the Brit. Med . 187 1 ,11, 2 5 5 . Drury, Was p

-stings (seven cases , w ith treatment), ih. , 35 1 .

“ Dea th

from the Sting of a Bee (female, aat. Lancet, ’ 1872 , 11, 135 . Po sada-Arango ,Le Po ison de Ra inette des sauvages da Cho c o ," Arch . de Med. xvi, 2 03 . Id . ,

No te sur les Sc orpions de la Co lumb ia , ” ih . , ih . , 2 13 . Fayrer,“ On the Ac tio n o f

the Cobra Po ison ,

” E din . J xvi, 62 3 . Anderso n , On the Use o f the Bro m ide ‘

o f Po tass ium in Rattlesnake Bites, ” Amer. Jo urn . Med . lxiii , 366 . W right ,On the Katipo o r Po iso no us Sp ider o f New Zea land, ” ‘Med.

-Ch ir. Rev,’

xlviii, 2 2 7.

In a prelim inary artic le on the patho lo gy o f hydro pho bia Rudnew187 1 , 3 2 1) asserts that the presence o f fo reign bo dies,

straw,hairs , &c Is no t

,as is generally assumed, an indicatio n o f the

disease ; that it is by no mean s co ns tant, and is no t a diagn os tic sign .

He has examined m icro s c o pically a ll the o rgans in the bo dies o f dogswhich died from o r were killed during an attack o f rabies . He ho ldsthat it, like alm o st all o ther infec tio us diseases , is c onnec ted with a profo und disturbance o f a ll the impo rtant o rgans . He c o nfines himselfin this artic le to the kidneys ; in a ll his cases there was a highly develo ped paren chym ato us inflammation the peculiarity o f which was thatb o th c o rtical and pyramidal po rtions were alike affec ted, presentingall the co nditions neces sary fo r the produc tion o f uraem ia . He thinksit extremely probable that the latter may be the cause o f many o f thesymptoms . A sec ond peculiarity was the degenerative c harac ter o f thenephritis ; in the m o st advanced and fatal stage o f the disease theurinary tubules were c ompletely bare o f epithelium

,and filled with a

granular, fatty, degenerated material .Allbutt showed to the Patho logical So c iety Lancet

,

’

1872 , i , 82‘Path . So c . xxiii

,1 7) m icro sc o p ic spec imen s from the cerebra l

c onvo lutions, the central ganglia, the medulla o blongata , and the c o rd,from two cases o f hydropho bia . The same m o rbid c onditio ns

,in dif

ferent degrees, were found througho ut —1 , evidences o f great vas cularc ongestion with transudation in to the surro unding tissues ; 2 , haemo rrhages o f vario us s ize, with apparent fibro us exudation ; 3 , smal l gap sdue to disintegration o f nerve-strands . The Spleen was enlarged inbo th cases .

McG il l,“ Two Cases of Hydrophob ia, ” Lan cet, ’ 187 1 , i , 53 7. Sainter,

“ Chlora lIn Hydrophob ia ,

”ih ., 1872 , i , 53 7. E lder, Cas es o f Hydro pho b ia, w ith remarks , ”


and c ourse o f the disease. Whether it b e po s sible to divide it intoseveral fo rms , as has been pro po sed (inflammatory, abo rtive, apo plec ticand paralytic ) , remains undec ided. T he auth o r thinks that the

variations in the c ours e o f the disease sho uld be referred partly to theinfluence o f individual c o n stitutio ns and tendenc ies , partly to pre

va iling affec tions ( “ c onstitutio ann i ” o f Sydenham . He callsattention to the unmistakable presenc e, in all the cases Ob served, o f a

rheumatic c ause and the c o inc idence o f the epidem ic with the com

paratively frequent o c currence o f “rheumatic tetanus . ” T he treat

ment c ons isted Of attentio n to the individua l c ase, lo cal bleedings , c o ldapplicatio n s to the head, and the employment o f calomel o r narco ticsa s the case demanded.

Ko tsono pulo s Bericht uber die in Nauplia im Anfange des Jahres1 869 aufgetretene Meningitis cerebro -spinalis epidem ica ‘V irc h .

lii,65) gives an ac c ount Of an epidem ic Of this affec tion which

bro ke o ut in Greec e in the winter o f 1868-69 . Nauplia was attackedearliest and m o st vio lently. The firs t cases were diagno sed as tho se o f

pernic io us malarial fever, o r simple meningitis . After trac ing the

Spread o f the disease, the writer des cribes its symptom s and co urse the

affectio ns Of the j o ints frequently preceding the meningeal symptom s

the injec tio n o f the c onjunctivae and eyelids at the commencement o f the

disease,no ticed in alm o st all c as es ; the rem ittent o r interm ittent cha

rac ter Of the disease ; the furious delirium , which dro ve the patientsn o t o nly from their beds but into the s treet . G enerally speaking, thedisease set in suddenly without any prodromal symptom s . T he articular pains were almo s t always present , generally attacking the wris to r knee-j o int, o r bo th at the same time . The pain was increased bypres sure, the j o int was swo llen and sometimes red, and fluctuatio nc o uld be detected. The jo int affec tio n began s ometimes befo re the

meningeal symptom s , o r o n the seco nd o r third day, and c o ntinuedthroughout the attack . The tetanic cramp o f the musc les o f the nec kand back was a characteristic and

,s o to speak , a pathogno mo nic

symptom s . Clonic cramp s and c onvul s ions o c curred in yo ung children .

Paralys is o f any kind, with the exceptio ns o f blepharo pto s is and strab ismus o c curred rarely . O ther symptom s o n the part Of the differento rgans are given in full . In almo s t all cases the affec tion was usheredin by a rigo r o f varying length and intensity , which o ften recurred in an

interm ittent fo rm . But little light is thrown on the etio lo gy o f thediseas e o r o n its treatment . Of n inety-three perso ns attacked the

greater number, twenty - six,were between the ages o f ten and twenty

years , and o f thes e the largest number between ten and fifteen . T he

autho r c on c ludes that it is a s ec ific infec tious disease,no t allied

,

as so me as sert, to typho id and malarial affec tion s .

Rus sell refers New Y o rk Med. J xv , 30 2 ) to the o ccurrenc e

o f seven cases o f spinal meningitis , in New Y o rk,within three days ;

three pro ved fatal .Stadthagen,

“ Ueb er Meningitis Cerebro sp inal is , m it b esonderer Berucksichtigungdc r letzen Berliner E pidem ic des W inters , Diss . inang . Berlin.

’ Maier,E in Sel teuer Fall vo n Meningitis Cerebro sp ina lis " (female ch 1ld, eat. 6 m o nth s ),

‘Jahrb . f. v, 109. Alix,

“ E p idem ie de Mén ingite Cérébro spinale,

Y ELLOW FEVER . 45

Gaz . des Clouston , Case o f Cereb ro sp inalMeningitis ” (in insanepatient, auto psy),

‘Journ . Ment . xvii , 2 2 5 . Dow se , Cerebro sp inal Men ing itis w ith Myelitis o f th e Cord ”

(wom an, set. 60 , auto p sy), 1872 , i , 756.

Tempini, Un c a so sporadico e fulm inante di Men ingite Cereb ro spinale (girl, s e t.1 1 years , w ith autop sy), Ga z . Med. Ita l . Lomb ard, ’ 187 2 , 2 3 7 . Hab ersh on , Diseaseo f the Ao rtic Valves , U lc eratio n of the Valves ; Acute Cereb ro sp inal Men ingiti s ;Os sified Aneurism al sac at the Commencem ent o f the Ao rtic Valves (m an , set. 4

Guy’s Ho sp . N . S ., xvii, 440 .

Intermittent Fever .

Bo isseau Gaz . 187 1 , 2 00) rec o rds a case o f trans ito ryaphas ia ac c ompanying an attack Of interm ittent fever . T he patient , as o ldier, set . 2 1 , had suffered from the latter affection in 1866

,while in

Co chin China . The attacks recurred every three o r fo ur days,while he

was in Belgium ,after the battle o f Sedan

,and again in 187 1 . At this

latter period, with o ut any paralys is o f the face o r limbs,the attacks

were ac compan ied by an aphas ia which returned at regular intervals .

T he same thing had happened during the fo rmer attacks o f ague .

Bazin Gaz . des 187 1 , 2 86) gives a case Of intra-uterine ague .

The m o ther was suffering from tertian ague at the time o f her c o nfine

ment, and gave birth to a female child during one o fthe attacks . N earlya m onth later

,and fo r s ome tim e afterwards

,the child had regularly

every n ight attacks Of c o ldnes s and paleness , yawned, and stretched itslimbs

,and a little later became red and burning ho t, its resp iration

increasing in frequen cy ; it then fell into a s leepy c onditio n,during

which it refused the breast ; towards mo rning the heat left it , and itagain res ought its natural fo o d. At the same time there was greatenlargement o f the spleen and oedema o f the feet , face, eyelids, 85 0. He

calls attention to the latter,which he c on s iders a great aid in the

diagno sis o f ague in yo ung children (l) .Longh i, “ Della Malaria e dell e Fehri Interm ittente, ” ‘Gaz . Med. Lomb 1872 ,

2 53 . Galt, Desc riptio n o f an E p idem ic Malarial Co lic wh ich prevailed at Iquito s,Peru, in the autumn o f ‘Am er. Jour. Med . lx iii 368 . Senato r,Ueber die Beziehungen zw ischen Feb ris Interm ittens und Recurrens, ” Berl . Klin.

W o ch 187 1 , 3 79 (ab stracted under latter fever). Curschmann, Bemerkungcn

ub er die Behandlung des Wech selfieb ers m it Carb ol saure,” ‘Deut. ix . 1 2 0 .

Biebuyck,“ No te pour serv ir a l ’Histo ire de la Fievre Interm ittente en Mexique ,”

‘Rec . de Mem . de Med. xxvi, 60 . Donaud,“ De l

’io de contre la F1evre

Interm ittente , ” Gaz . 187 1 , 434 . Pasta e Ro tondi Sulla v irtuMedicam en

to sa del Citrato di Chiniodina, ” ‘Annal . Univ. di Med ., vo l . 2 18, p . 609. Roy,On the Therapeutical Actio n o f Quinine on Malaria, ” Lanc et, ’ 187 1 , i, 2 45 . Gee,The Urinary Ph o sphates in Ague, ” St. Barth . Ho sp . vii i 3 2 .

Y ellow Fever.

Munro E din . xvu , 2 0 1) gives some no tes on cases o fyellowfever

,which o c curred between September, 1 868, and January, 1870 ,

in

the usually very healthy island o f St. Kitt’s . All the evidence he hasbeen able to c o llec t inc lines him strongly to the c o rrectnes s o f the

infec tion theory,

” th ough he do es no t rejec t the idea that it c an a ls o

o riginate de novo . He believes,indeed

,that the first o f the cases he

gives probably aro se in this way, the atmo spheric and b ad hygienic c o nditions which surrounded it acting as causes . The firs t case was that


Ofa b oy, act. 7, who , two weeks befo re he was attacked, had been bro ughtto the town o f Bas seterre from Grenada , at which place , s o far as theautho r c o uld dis c o ver, there was n o yellow fever at the time. Freshc ases o c curred in the neighbourho od o f the ho use in which this patientdied. The disease spread gradua lly from house to house and from plac eto place ro und the who le island. One hundred and eight peo ple in all

were attacked, o f whom fo rty-fo ur, o r 407 per cent. , died . E uro peans,

and espec ially tho se just cOme out, seemed mo s t sus c eptible ; then the

Po rtuguese, nearly al l natives o f Madeira . Munro thinks that a

faecal cause” for the disease m ay be fo und in the fac t that thegreater part o f the town o f Basseterre had been destroyed by fire inJuly

,1867, which, by burning down the privies , left their pits o pen

,

the neces sary atm o spheric c onditions fo r the pro duc tion o f the feverno t o ccurring till fifteen mo nths later. He gives an ac c ount Of a

number o f the cases and tables o f the rainfall , barometric pressure,850.

Sullivan ,in his N o tes on the Y ellow Fever

, as observed at Havanain 1870

” Med. Times and 187 1 , i , gives a very full ac co unto f its different fo rms

,its symptoms

,and its treatment . He remarks

that in fatal cases jaundice is as certa in after death as album inuriaduring life . He draws attention to the means Of diagno s ing betweenthe true black vom it and deep

-co loured bile ; linen steeped in the

fo rmer gives afiis lre tres tranehée in bile,a green o r deep yellow . As

to the nature Of yellow fever, he c onsiders it a pes tilential o ne, havingtwo distinc t phases—o ne o f reac tion against the infec tio us po iso n ,

c o n

stituting sometimes the entire malady, and very like an infec tio us feverthe o ther

,o f depres s io n o r adynam ic ataxia, c ounterfeiting nervous

haemo rrhagic putrid fevers .Hiron (ib . , 1871 , ii , 1 2 4) gives a long and mo re o r les s confused

ac c ount o f the ep idem ic o f yellow fever in the River Plate distric ts in1870 and 187 1 . It had already shown itself at Ascension in the

summer o f 1869-70 , and in Apri l o f the latter year had appeared at

Bueno s Ayres . As far as co uld be disco vered it had been impo rted intobo th places from Rio Janeiro , but did no t spread far at the time .

During the next summer it broke out in bo th p laces and at Co rrientes .

Bueno s Ayres has a po pulation o f abo ut Of these,fled at the beginning o f the o utbreak ; o f tho se that remained threefourths sickened and o ne fourth died. There seem s no doubt that thedisease was impo rted from Bra z il, mo st pro bably aided by insuffi c ientquarantine arrangements . Bo th Monte Video and Ro sario , at whichp laces quarantine was carefully Observed, were free from the diseas e .

T he writer discusses the effec t o f the atm o spheric c onditio ns . T he

Italian part o f the po pulation ,who are the po o rest

,and inhabit the wo rst

quarters o f Bueno s Ayres , sufferedmo st, and the affection was espec iallyfatal among ch ildren . The po st-mo rtem appearan ces and the symptom s are s im ilar to tho se already rec o rded

,and

,as far as treatment is

c o ncerned, the writer agrees with Sullivan .

E ulenberg Berl . Klin . 187 1 , 174) writes on the epidem ico f yellow fever in Rio Janeiro during the years 1869 and 1870 . T hesummers o f these years and Of 1868 had been marked by great dryness

CHOLERA. 47

and absenc e o f sto rm s,and the s o il-water sto o d extraordinarily

deep at the same time the epidem ic was preceded, as in fo rmer

years , by an epidem ic Of Dengue, which Nageli and o thers lo o kupon only as an aborted fo rm o f yellow fever . As usually is the c ase

,

the po o rest and filthiest inhabitants suffered mo st , the epidem ic spreading rapidly am ong the suspec ted c o al-ships in the harbo ur ; 599 patientswere treated in ho spital between Feb . 4 and March 18

,1870 , and o f

these 99 (1 78 per c ent .) died.

The Pall Mall Gazette ’ gives (Feb . 2,1872 , 5 [76 the fo llowing

In an interesting report , lately issued by the health o fficer o f the

po rt o f Charleston ,South Caro lina, the cause o f yell ow fever in that

c ity is traced to putrefying o rganic m atter . It appears that the so il onwhich the c ity stands is sandy and porous , and c onsequently well ca lculated to c o nceal po isonous gases, and that the sewerage is altogetherdefective . Last year

,when the epidem ic raged m o re severely among

the co lo ured residents than it had been known to do previo usly fo r thirtyyears

,the health Offic er shows that during the five ho t m o nths, from

May 1 to Sept . 2 5 , only one ves sel arrived in po rt having a case o f s icknes s on bo ard

,and that case was no t yellow fever. T he disease, there

fo re, co uld n o t have been impo rted. Further than this the hea lthOfficer states that the c ondition Ofthe atm o sphere las t yearwas like thato f 1850 ,

when there was ano ther terrible o utbreak Of yellow fever as itis po s s ible to find in two different seasons . In bo th in stances Charleston was expo sed for weeks to intense heat, and this was fo llowed by a

deluge Of rain .

”

Johnston, Repo rt on the Ep idem ic Fever at Trinidad, ‘Army Med. Rep .

for 1869, xi, 363 .

“ Report o n Outbreak o f Y ello w Fever at Mandeville, Jama ica,ih . , 389. Ul lersperger,

“ Das gelbe Fisher in Valenc ia, ” Deut. 187 1 , 1 1 7 .

Y ellow Fever in Bueno s Ayres , ” New Y o rk Med . J xiv . 1 1 1 . Bailey, T he

Nature and Treatm ent o f Y ellow Fever, ” ib ., xv, 44 . Anderson, Y ellow Fever as ito c curred in Wilmington, No rth Caro lina, from 1800 to ih . xvi, 2 2 5 .

Cho lera .

Bo tkin Berl . Klin . 187 1 , 389) gives very full o bservahtions , made with reference to the symptom s and treatment o f cho lerao n twenty-three male cases in ho sp ital in St. Petersburg. T he Ohservations were made during the March and April o f 187 1 . Of the

twenty-three, on adm ittance into ho spital, the temperature was belowno rma l in twelve

,and o f these four died ; in seven it was high, and in

the rest no rmal . After entering into the state o f the vario us o rgan sand secretion s and the treatment (with la rge do ses o f quinine) , he giveshis opinion that the cho lera pro ces s is no t the result o f a lo cal effec t o fthe cho lera-po ison , but the expression Of an infection Of all the fluidso f the bo dy. One o f his ass istants, Dr . Po po ff, injected the fresh vom ito f cho lera patients into the vein s o f dogs , and o btained a c ondition re

sembling the c lin ical c o ndition Of cho lera , together with charac teristicchanges in the intestina l canal . T he disease , a c c ording to Bo tkin, maybe fatal without any pro fuse diarrhoea, and it is in co ns istent to refer thecyano s is , the dyspnoea , the cramps , &c . , to the lo ss o f fluid and thickening of the blo o d. He uses quinine on the princ ip le o f its emp loyment in


s im ilar infectious diseases , and lo oks up on it as a pro phylacticHe ho lds that in the m o de o f its develo pc lin ical and anatomical aspects

the cho lera pro cesprofuse sweating, pain and enlargement o f hver and spleen , scantysecretion o f urine, which was s ometimes album ino us , and during co n

valescence herpes labialis , epistaxis, catarrh o f the no se, thro at, and

bronchi,tendency to diarrhoea , &c . This type was Observed in pers ons

o f all c las ses and ages , attacking in many fam ilies several individuals ; itwas at first sporadic , but was pro pagated in an epidem ic fo rm a sho rt timebefo re the outbreak o f the cho lera . He has never no ticed that these c asesbecame cases o f cho lera , but al l c ho lera patients admitted into ho spitalhad suffered for severa l days with prodromal symptoms, which m o re o r

less co rresponded with the affectio n described. He believes he is justified in c onc luding that this is an independent affec tion allied to thecho lera pro ces s ; that it is the result o f the ac tion o f a cho lera po is on

,

probablym odifiedby external influences that this mo dified po is o n bearss omewhat the same relation to the true cho lera virus as that o f bilioustypho id do es to that o f recurrent fever, o r that o f abortive typho id tothe true typho id fever and he inc lines to the view that the cases no tic edby previo us writers o f gastric and intermittent fevers preva iling duringo r after epidem ic s o f cho lera belo ng to this fo rm o f the affection , in

which sho uld be rec ognised a modificatio n o f the cho lera infec tion , an

abo rtive fo rm o f the disease . His treatment o f these abo rtive ” casesc ons isted in the administratio n o f p ills c o ntaining carbo lic ac id and

quinine .

Paters on Med. Times and 1872 , i , 473) has made experimentso n dogs , rabb its , and m ice, with the ric e-wate r sto o ls o f cho lera patients ,in the c ondition o f deep co llapse . Some o f the experiments werem ade with the fresh matter, o thers with the cho lera matter in a s tateo f fermentation . N0 result was Obtained in any case .

Lawso n (ih .,187 1 , 11

,1 5 ) gives some very interesting Ob servatio ns

o n o utbreaks o f cho lera in ships at sea,which

, as he has befo re laiddown , have fo r their cause the Pandemic waves ” which travel unifo rm ly from so uth to no rth acc ording to definite law .

”

Wittcke Zeitschr. f. iii,2 04) gives a sketch o f the

ep idemic o f cho lera in 1866 at E rfurt,wh ither it was intro duced from

Berlin . It broke out on the 2 3rd July, and was extinguished by No v. 15 .

It wa s the m o st extensive ep idem ic that ever broke o ut in that dis tric t,and though it attacked a les s number o f perso ns than the epidem ic o f1850 ,

the m ortality was greater. In the latter year 3819 were at

tacked, Of whom 13 1 2 died ; in 1866,1539 died o ut o f 2 65 0 ca ses .

Striking pro ofs were o btained Of its c ontagion by individua ls o r infected o bjects . Ac c o rding to Wittcke

,Pettenkoffer

’

s views as to the

CHOLE RA . 49

relation Of certain c onditio ns’

o f subs o i l water to cho lera were no t suppo rted by this ep idem ic ,

no r did the direction s given by him as to the

disinfection o f latrines , &c . , pro ve m o re effica c ious . The affec tionvis ited several pla ces which had been perfectly free, and spared o therswhich had suffered, in fo rmer years .

Mo o re translates Brit . Med. Chir. xlviii, 462 ) a paper by

Schleisner, on the cho lera in Co penhagen in 1866 . Thirty c ases Of

cho lerine, suspic ious diarrhoea, and cho lera rema ined on bo ard ship inthe ro adstead, o f whom two died ; sixty-one , o f whom six died, wereadmitted into the ho sp ital . In the c ity itself only fo ur c ases o ccurred,o f which the first died. This immunity o f the c ity, to the p ort Of

which 2 2 33 ships arrived between May and December from infec tedlo calities , was due to the stringent measures adopted. These the autho rgives at length—strict quarantine ; daily inspection Of the ship s fo r thefirst three days o f their stay in harbour ; strict regulatio ns as to lo dging-houses and inn s , as regarded the reception o f seafarers , &c . ; the

fo rmation o f a cho lera ho spital in an iso lated po sition near the harbourdis infec tion o f all latrines ; spec ial s upervis ion o f the c ity itself by thesanitary po lice ; and o f al l institutions , orphan ho uses, scho o ls , &c .

,by

the medical Officer o f hea lth and the rem o val o f the o ccupants Of suchhouses as m ight b e first attacked by cho lera .

Thompson gives a report Army Med. Rep .

’fo r 1869 , xi, 39 2 ) o n an

epidem ic o f cho lera at Thayetmyo , British Burmah , in 1869 . A po rtiono f the 76th regiment was stationed there from February, 1868, to April,1869 . At the end Of the latter m o nth cho lera

,which had no t appeared

befo re,bro ke o ut in a c o o lie village . In May ,

it attacked a barrack inwhich the married s o ldiers lived

,and spread rapidly, till they were re

mo ved to a m o re elevated and easily iso lated spo t , when no furthercases o c curred.

Fauvel Bull . de l’

Acad. de xxxvi,

read befo re the

Academy som e no tes o n c ho lera,in which he sketches its march in E urope .

In Rus s ia,where it never entirely disappeared s ince its impo rtation in

1865 , it was still epidem ic , at the end o f 1869 , in several pro vinces in .

the centre and the west . It gradually dimin ished, till it seemed to

have disappeared abo ut the m iddle o f 1870 . In July o f that year itagain bro ke o ut at Taganrog and Ro stow

,spread along the sho res o f

the Black Sea by Kertch , Odes sa, and Po li, from whence it was prOpagated inwards to the transcaucasian pro vinces . The rapid extens ionalong the c o ast co inc ided as usual with the arriva l o f travellers fromaffec ted parts . It was by no means severe and c eased again at the endo f September. In the early part o f that m onth a few cases Occurred in

St. Petersburg, where it reappeared in February, 1871 , and was regularlyepidemic . In May it also broke out in Mo scow and the neighbo uringpro vinc es ; next m onth atWilna, at Sulwalki, no t far from Koenigsberg,and at Riga ; at N ijui-N owgo ro d, and Kazan ; and in the south againat Taganrog, where it raged with espec ial vio lence, 1 people beingattacked between June 1 2 and July 2 2

,o f wh o m 4489 died (ib . ,

At the end Of July (187 1) it appeared at Koenigs berg (ih .

, in

August suc ces s ively atDantzig, Stettin , Berlin , on the 19th at Po sen , and

on the 2 9th a t Frankfo rt -o u -the-Oder,and almo st at the same time at

4

50 REPORT ON P RACTICAL ME DICINE .

Hamburg and Altona , on the E lbe. These places were the mo st wes twardlim it

, as Frankfo rt, &c .

,were the mo st s outhern ,

o f the cho lera in 187 1 .

At Koenigsberg 2 635 were attacked, and 1 2 04 died, In spite o f rigo rousquarantine measures , the disease extended also in the s outh-east . In

September, 187 1 , fatal ca ses o c curred in a village o n the Bo spho rus ,and at the end o f . the m onth in Constantino ple , where 1 1 2 died in six

days . It also appeared at Galatz . In a further c ommunicatio n (lo c . cit .

,

1872 , series 2 , i , Fauvel resumes his sketch , with espec ial reference to the o utbreak o f cho lera at Mec ca and Medina (Feb .

,

Barnier Arch . de Med. Navale, ’ xvi, 190) publishes a no te on an

epidem ic in September and N o vember, 1870 ,in the island o f No ss i-Bé,

in lat . 15'

5° south . It was brought by a negro from Madagascar, where

cho lera was present , on 15th Septemy r,to the village Of Ambanourou .

Next day fo ur peo ple who had been In c ontac t with him,died ; and the

affectio n spread rapidly . The village, the po sitio n o f which made it easy,was iso lated by land and sea ; but the quarantine arrangements werebroken ,

and the disea se wa s propagated to Ankarankel and to Hellville,

but owing to the strict arrangements did no t bec ome general . It wasm o st fatal among the Caffirs , 168 dying o ut o f 2 04 attacked. Am ong 2 00

Indians there were but three cases and one death . Barn ier thinks thatthe idea that this po ison is pro pagated by the air is radica lly fal se ; andthat

,however saturated with c ontagion the air may b e in a town where

cho lera is raging, it entirely lo ses its deleterio us ac tion in a distance o f

les s than a kilometer from the place .

Pellarin Gaz . 187 1 , 533) gives sho rtly his experience o f

an epidem ic o f cho lera in Guadelo upe and o ther islands Of the Antilles ,far surpas sing in vio lence any seen in E urope . N o thing was to b eno ticed as far as atm o spheric o r even the lo cal hygienic c onditions waso bserved. N o r was the epidem ic preceded by any analogo us o r pre

m onito ry affections ; and he c oncludes that the his to ry Of insular epi

dem ies pro ves that they are directly and always preceded by the introduction into the island either o f patients sufferin from the diso rder,o r artic les impregnatedwith the c ontagious princ ip e . Mediate o r m is smatic c o ntagion is the only mo de o f pro pagatio n Of cho lera in islands .

Ro lleston Lancet,

’

187 1 , ii, 339) pro tests against the theo ry thatwater is the o rdinary vehic le

,and

,so far

,the s o le cause o f cho lerafilF

On the o ther hand, Dr. Benzy (“ Water Theo ry o f Cho lera , ” Med.

Times and 1871 , i , 4 1 1 ; Lancet , ’ 187 1 , II, 449 , 62 3 ; Brit.

Med. 187 1 , ii, 62 6) finds fault with Ro llesto n,Cunn ingham ,

and v . Pettenko fer,and attempts to upho ld his favourite theory .

S ct mann Berl . Klin . 187 1 , 43 I) fo und very great suc cessin the cho lera ep idem ic o f 1866

,in Texas

,from the employment o f

quinine combined with Opium . Reichard (ib ., in the ep idem ic at

Riga in 187 1 , fo und chlo ral hydrate give go o d resul ts . Ro the (ib .

,

348 from the employment o f carbo lic ac id in the diarrhoea o f infantsand in spo radic c ases o f cho lera

,thinks it will be o f great use

in c ases o f the epidem ic disease . Fo rs ter (ih . 446) advo cates the4“ T he different ab stracts given in th is report suflic iently c onfirm th is pro

wh ich it would b e well for o th ers be s ide the writer o f a “ leading Lo ndo n po litip aper

”to lay to heart

—A. B . S .

5 2 REPORT ON PRACT ICAL MEDICINE .

Weisb ach , “ Beschrankte Cho lera-E rkrankungen in der Berl iner Charité im Jahre‘Virch .

Arch IV , 2 49 . V. Kaczow ski, Bericht ub er die Ch o lera-Epidem iedes Jahres 1866, in Po sen ,

” Berl . Klin . 1872 , 15 . Nedsvetski,“ Zur Mikro

graph ie der Cho lera ,” 1872 , 2 33 .

E nteric (Typ hoid) Fever .

Hesch l (‘Wien . Med. 187 1 , N o . 34) is c onvinc ed that thec apillaries and musc les o f the intestinal cana l are infiltrated in the same

way as the fo llic les and the sub -mucous tissue, and to this c ause herefers the deeper degenerative changes which lead to perfo ration .

He des cribes in full the m icro s co pic changes fo un d, bo th in the c apil

laries and the longitudinal layer o f the inte s tines : in bo th the nuc leiare enlarged, and in different stages o f pro liferation .

Murchison Path . So c . xxii , 144) describes the changesfound in the intestine Of a man

,set . 2 4, who se bowels had been c o nsti

pated througho ut, and who died o f haemo rrhage o n the twenty-seventhday o f the enteric fever. T he haemo rrhage did n o t seem to have proceededfrom o ne ulcer in particular, but to have been due to a fungatingc ondition o f the m o rbid material in many o f Peyer’ s patches neares t tothe caecum ,

c o rresponding to which were dark-red spongy exc rescencesfirm ly attached to the subjacent ulcerated surface .

Mac lagan E din . J xvi, 865) writes a long paper o n the

intes tinal les ion o f enteric fever, and in an appendix gives no tes o f

th irteen cases . He briefly summarises his fac ts as fo llows . T he in

testinal lesion o f enteric fever is Specific in charac ter, and may term inate in reso lution o r ulceration . When it goes o n to ulceratio n thereare two

part Oftion o f

relative frequency o f these twextent o f the primary les io ns .

the attack,while that o f the s e

likely to predom inate in cases in whic h the general symptom s areand the

oprimary lesions few . One primary lesio n is suffic ient to

duce,directly o r indirec tly

,many sec o ndary . T he discharges do

neces sarily ino culate every gland o ver which they pas s the longerremain in c o ntac t w ith a gland, the m o re likely ishigher up in the in testines the primary lesion s are

numerous,c ceteris paribus , will be the seco ndary .

lesio ns . Relapses are c aused by a reabso rption o f thesystem,probably by one o rm o re abso rbent glands whichthe primary attack . Co n stipation is to b e regardedultimate danger. N0 o ne suffering from enteric fever Sho uld gothan two days witho ut a sto o l .Allbutt Brit. Med. J 1871 , i , 547) draws attentio n to

in which the patient, witho ut the exis tenill he becomes a living skeleton .

ENTERIC (TY PIIOID) FEVE R . 5 3

believes that the innutrition cons ists in the lack o f digestive powers o verfats . In the absence o f any patho logica l pro o f at present, he refers thecause to a permanent degeneration o f the m esenteric glands .

Guénio t Gaz . des 1 871 , 30 1) rec ords a case o f haematomao f the rectus abdom inal musc le in a man o f 2 2 reco vering from typho idfever.

Kraft-E bing Deut . vi ii , 6 13) gives two cases o f suppurationin musc les after typho id fever. The firs t was that o f a man

,set . 2 4,

c onvalescent from typho id, in whom a fluctuating tum our appeared,c o rrespo nding to the same rectus musc le . T he writer believes thatthere was here a rupture o f the degenerated musc le

,fo llowed by

haemo rrhagic infiltration that the latter set up inflammation go ing on

to s uppuration ; and that had no t in c is ion been made thro ugh the skin ,

&c .

,the pus m ight easily have found its way into the peritoneal cavity .

In the second case,a man

,set . 2 2

,died o f pneum on ia o n the fo rty

third day o f a severe typho id fever. At the auto p sy the who le leftps o as muscle, from an inch from its o rigin down to Po upart ’ s ligament,wa s changed into a tum our

,which on being o pened gave exit to ill-smell

ing pus , m ingled with blo od, blo o d-c lo ts , fibres and c ell-tissue . The in

ternal iliac and a p o rtion o f the tran sverse abdom inal mus c le were als oo f a yellowish -red c o lo ur

,and c ontained partly fluid

, partly c lo ttedblo od. The m icro s c o pica l exam ination Of all these mus c les showed thefibres infiltrated with a c loudy

, granular, highly refrac ting material,

the striations partly destroyed, no amylo id degeneration ,o r rupture

(Bruchspalten) . The autho r c onc ludes that suppuration may o c cur in

typho id fever, from haemo rrhage into musc les,and that this depends ,

as Zenker has sh own ,from antec edent degenerative changes in the

fibres .Clément Lyon viii

,649) rec o rds a case o f typho id fever in

a man , set. 2 2 , fo llowed by c omplete right fac ial paralys is , with paralysiso f the o rbicularis and lo ss o f elec trical contra ctility paralysis o f the

sens ory p o rtion o f the trigem inal , the glo ss o -

pharyngeal, audito ry,

hypoglo s sal and o lfac to ry nerves and para lys is bo th Of m o vem ent andsen sation in the limbs . He refers the o rigin o f the les ion to the

medulla oblongata .

Gluge Bull . de l ’Ac ad . Med. v,6 13) rec o rds the fo llowing

as a rare term ination o f typho id fever . A b oy, act . 6 years,c onvales cent

from the disease,was attacked a month after its c ommencement with

periton itis,and very c ons iderable purulent effus ion , which made its way

out by the umbilicus . The child rec o vered and the Opening had c lo s eda month later .

Latham Lancet, ’ 187 1 , ii , 81) c oncludes from his own experience(1) that a lmo s t invariab ly the disease (typho id fever) pro c eeds from a

special po is on c ontained in the a lvine excreta . (2 ) That this po is on i sdirectly intro duced into the alimen tary c anal

,either in the fo o d

,o r

,

mo st generally, in the water drunk . (3) That it is no t yet pro vedthat the po is on i s c ontained in ,

o r is dis s eminated by,the exhalation s

from drains , privies, &c .

,o r that it can b e abso rbed into the system

through breathing air c ontaminated with such exhalations . He

describes an o utbreak o f typho id fever at Harston , near Cambridge ,

5 4 REPORT ON PRACTICAL ME DICINE .

and suggests , ( 1) that every evacuatio n ,as so o n as pas sed, sho uld b e

disinfec ted with c arbo lic ac id. (2 ) That n o surface-well water o r

pump-water, whether bo iled o r no t, Sho uld b e usedin.

a distric t wherethere are any c ases o f typh o id fever, but that all drinking water shouldbe Obtained from s ome spring no t liable to c ontagion . He po ints outthe impo rtance o f no t giving s o lid fo o d till the temperature o f the

patient at 8 a m . and 6 p m . has remained, fo r two days at least, aboutthe normal po int, when we may be sure the ulcers have healed .

In a long “ Inquiry into the c auses o f Typho id Fever, as it o c curs inMassachusetts ” (‘Sec ond Annual Report o f State Bo ard Of Health o f

Massachusetts ,’ 187 1 , p . it is co nc luded that “ it is exceedinglyprobable that a ric h and fertile s o il on which decompo sitionab le sub

stances are retained near the surface b y any cause, whether a c laysubso il, o r a ledge o f ro ck , o r a pro tracted drought, is a so i l favo rableto the production o f this spec ial disease.

”

N . Ratc liffe Lancet, ’ 187 1 , i , inquiring into the o utbreak o f

fever at New Barnet, found the sewage arrangements o f the ro ad, in

which individuals were attacked, two o f them fata lly, to c ons ist o f fo urlarge cesspo o ls fo r thirty o r fo rty ho uses, or m o re . T wo o f these ces s

po o ls were o pen and two c o vered, the two o pen o nes receiving theo verflow from the latter, the fetid sewage ultimately finding its way byOpen trenches into the river Lea .

Mayo Med. Times and 187 1 , i i, 492 ) describes an arrange

ment o f the same kind in a village near Oxfo rd,in which an epidemic

o f typho id fever had broken out . The inhabitants seem to b e m o stfilthy in all their habits . At the back o f a ho use where the wo rs t caseso ccurred ran a ditch into which the peo ple o f the hamlet threw al l theirS lops . The drinking water o f this c o ttage was o btained from a pumpo ppo site . A drain , made o f rough s tones

,brought the l ps from two

o ther co ttages , and passed c lo se to this pump , the dis tan ce from the

c entre o f the pump (which sto o d o ver its well) to the m iddle line o f

the drain being two feet six inches .

Lis sauer (‘V irch . liii,2 66) gives his experience Of the anti

pyretic (c o ld water) and the expectant treatment o f typho id, during thelate campaign , at Metz , Compiegne ,

and Ro uen . Under the fo rmer he

lo s t 6 out o f 97 (i. e . 6 18 per cent ) , and under the latter 1 1 out o f 46

(i. e. 2 39 1 per cent) . At Ro uen,from the unhealthy p o s ition o f the

ho spital, 5 o ut Of 13 , treated on the expec tant plan , died. The cascadetreated with c o ld water were severe thro ughout tho seo ther plan were in great quantity lighter c ases

,so th

o f m o rtality under the two can s carcely be c ompared.

employed three times a day in tho se cases only in whiture ro se abo ve 4 1° C . In the majo rity o fin the day were suffic ient

,espec ially if c ombined with

quin ine . He gives the temperatures o f s ix ca ses in ful

a chart o f each .

The co ld-water treatmentby Binz and o thers

,referenc

Scholz (‘Deut . ix

treatment o f typho id in 1 2 5

E NTE RIC (T Y PHOID) FEVER . 5 5

five (fo ur men and a woman) died. T he patients were Of all ages ,between 10 and 50 years . T he temperature Of the bath was ac c ordingto age, 50

° —68° F . ( 10°— 2 0

°

and the period o f immersion five toten m inutes, with the addition afterwards o f c o ld application s . Drugswere given but rarely : casto r Oil in c o nstipation ,

the tinct . ferri perchlo r. in haem orrhage from the intestines . The latter c ontra - indicatesimmers ion in c o ld water, on ac c ount o f the abso lute rest necessary forthe patient, but no t the use o f c o ld applicatio ns . The paper c ontains afull ac count o f the sequelae no ticed, and the autho r adds that he hasfound the co ld-water treatment m o st suc c es sful in the acute infectio usdiseases (scarlet fever, measles , diphtheria , erysipelas) .Po pper Oestr. Zeitsch . f. NO . i) Obtains the same go od

results from this treatment . Of twenty cases Of typho id, one onlydied. T he bo dy was only half immersed in c o ld water fo r ten to fifteenminutes, the rest o f the body sprinkled with it, and c o ld c ompres sesused afterwards . The bath was employed twice a day .

Lieb ermeister, “ Notiz b etreffend die Epidemic in Andelfingen vom Jahre 1839,‘Deut. ix, 245 . Vircho w ,

“ Kriegstyphus uud Ruhr,” ‘Vireh . lii

, 1

(ab stracted under typhus) . Heine, Ueber die Behandlung der Blattern und des

Abdom inal-typhus, ih . , liv, 2 1 7. Weiser, “ Zur Hydro therap ie des Ileo typhus, ”Wien . Med. 187 1, NO . 2 2 . Bo hm and M ich el, “ Beobachtungen fiber die

Kaltwas ser-b ehandlung des Ab dom inal-typhus im Kriege, ” Deut. vii i , 596.

Billiard, Traitem ent ab o rtif de la Fievre Typh o ide par l ’em pl o i du Seigle E rgo té,‘Bull. dc l ’Acad dc Méd. dc Paris, ’ NO . 35 , p . 845 . Mo rache,

“ De l’

emplo i dc laCreasote a l ’ intcrieur dans le Traitement de la Fievre Typh o ide, ” Gaz . des

187 1, 394 . Témo in ,

“ Sur le Traitement de la Fievre Typho ide, ” ‘Bull . Gén . de

82 , 1 28. Leub c ,“ Mittheilungen i

'

i b er die Typhus -E pidem ic in der

Fes tung U lm im W inter 1870 -7 1 , und ihre Behandlung im dortigen Barackenspitale,”

Deut. vii i , 583 . Ho lzner, E p idem is che E rkrankungen in der PraparendenSchule zu Freys ing im Juli, ‘Zcitschr. f. vii , 306 . V. Pettenko fer,Typhus und Cho lera und Grundwas ser im Ziirich ,

”ib .

, V ii , 86 . Woh lrab , E inigeFalle von Verb reitung des Typhus Abdom ina lis durch das Wasser,

” Arch . d . Heilk . ,

xii, 134 . P feifer, “ Statistik der Typhus -Abteilung aus dem Reserve-LazarcthWeimar,

‘Berl . Klin . 187 1 , 105 . SchOnheyder,“ Beitrag zu einer

Charakteristik ii b er den Typhus b ei der Cernirungsarm ce vo r Paris, ” ih . , 103 .

Strub e,“ Beitrag zur No so logie dcr wahrend der Belagerung vo n Paris b ei der

Maasarm ee b eob achteteii Typhus E pidem ic , ” ih ., 355 . Finckelnburg ,“ Ueber das

Auftreten der Dyscnterie und dc s Typhus unter der Belagerungsarmee vor Metz , ”ih . , 369. Hjalteln,

Pyth ogen ic Fever in Reykjavik during the Summer o f 187 1 ,Edin . J m m

, 7 10 . Fergus, On the San itary Aspect o f the Sewage Questio n,with Rem arks on a little no ticed cause o f Typho id Fever and o th er Zym o tic s , ’ ih . ih .,

7 17. Taylor, “ No tes Of 3. Recent E p idem ic O f Typho id Fever, and its Mode o f

Propagation ,

”ih ., xviii, 1 24 . Galto n,

“ Perforatio n o f the Bowel in Typh o id Feverthrough a Divert ic ulum Ilei ” (b oy, set. Path . So c . Trans xxii i, 103 . Mac lagan,

The Bowel-Lesio n in Typh o id Fever, its Nature and Treatm ent, Lancet,’ 1872 , i,Typho id Fever, ih . , 536. Ro ll eston, On

ih . , 187 1 , 1 , 7 . De Renzy,“ The

Binz , Th e Antipyretic Treatm ent o f Typh o id Fever at th e Seat o f W ar,”ih . , 187 1 ,i, 147. Andrew ,

A Case o f Typh o id Fever c om p lic ated by Haematuria and Pro staticAb scess , leading to E xtravasation Of Urine ” (m an

, act . 35 , autop sy) , ih . , i i, 7 1 2 . Sutton ,Case of Typh o id Fever w ith High Temperature , the b ath unsuc ces sful , large do sesof quinine quickly fo llo wed by a fall o f tem perature ” (woman,act. ih . , 1872 , i,46. Hayden ,

“ Typho id Fever, Uraem ia , Death , ” Brit . Med . 1871 , i, 63 ,

Nunn, Suppuration o f Knee-jo int, Typh o id Fever, Pyaem ia, Death ,” ih ., 532 .

5 6 RE PORT ON PRACTICAL MEDICINE .

Kemp .Latent Typh o id Fever,U1ceration , Periton itis , Dea th (boy , zet a ih ii , 1 14 .

Hogg , E nteric Fever ”

(Statistic al), ‘Med. Tim es and 187 1, 11, 75 2 . Orto n,Typhoid Fever ”

(histo ry o f o utbreak atNewca stle-under-Lyme, in Decemb er, 187 1),ih . , 1872 , i, 459 . Wunderlich , Ueb er Darmb lutungen b ei Typhus Abdom in al isunter derKaltwasserb ehandlung, ” Arch . (1. xi ii, 48 1 .

Virchow Contagio sita t dis Fleckfiebers V irch . liii ,from o bservations o f the cases Of typhus o c curring in Berlin in 187 1 ,is m ore c onvinced that it is intro duced and pro pagated by direc t co ntagion , and does no t arise spontaneously . O f the 15 ca ses Observed theexanthem appeared o n the third day in tw o , and on the s ec ond day in

two also after the first rigo r : in s everal cases the gastric disturbanc ewas s o great as to sugges t cho lerine , espec ia lly as muc ous cho lerafungi ” were fo und in the He c omes to no definitec onc lus ion as to the period o f inc ubation . In o ne ca se the facts seemto po int to the po s s ibility o f infec tion in the last s tage .

In ano ther artic le Kricgstyphus und ih . lii , 1 ) the same

autho r writes o n the so -called war typhus . He ho lds that it inc ludesbo th typhus and typho id. As diagno stic o f typhus he calls attentionto the early appearance o f a ro seo lous o r measly eru tio n, generallythickly andwidely spread, espec ially o ver the face and exo r surfaces o fthe hands and feet . Petechiae were almo st absent in the majo rity o f

cases o f typhus , and frequent in tho se o f typho id. In the latter theeruption was scanty and lim ited to the upper part o f the abdomen and

the lower part o f the thorax, and only exceptionally general . In relapsing fever Virchow has m et s ometimes with haemo rrhagic petechiie ,

but

never a true exanthem . He asserts that the diarrhoea o f typho id is no tdependent upon fo llicular ulceratio n ,

but upon the c oncurrent catarrhOf the intestine ; that s tress sho uld b e laid, no t upon the ulcer but thes o - called medullary infiltration o f the fo llic le , inasmuch has no ulceratio n need o c cur in s ome cases

,and the so -called typho id scab represents

o nly a cheesy metam o rpho s is o f the infiltrated elements , fo llowed bythickening and lo o sen ing, and in this way a sec o ndary ulc er o f the

mucous membrane . He draws attentio n to the fac t that bo th in the

American and the Franc o -German ic w ar true typhus was extremelyrare

,while typho id Showed itself in the later stages o nly o f the m iseries

pro duced, and then gradually increased in extent and severity .

Lyon s Lancet, ’ 1871 , i, 708, 7 43) Oppo ses the V iew o f Ro lleston,

stated in a paper o n Typho id o r E nteric Fever in Indian Gao ls ” (ib . ,

i, and ho lds that typhusfever in Rawul Pindee gao lsand no t enteric o r rem ittent fe

1867, NO . 2 1, p. 107, and 1864, NO . 18

, p . 1 2 2 )o f the disease. Other medic al "o fficers have seen typand elsewhere o n the no rth-west fro ntier. Betweeno f 1869,563 c ases o f typho id o c curred at Rawul F

were fata l . He ho lds that there can be no do ubt o f

RELAPSING FEVE R . 5 7

which he prefers to lo ok up on a s o ne Of acute petechial typhus ratherthan Of cerebro -spinal meningitis .

Relap sing Fever .

Tennent G lasgow Med. n . S . , iii , 35 5) gives at s ome lengthan analys is o f 35 2 c ases o f relaps ing fever admitted into the G lasgowFever Ho spital between March 16 and O ct. 2 0

,1870 . Six of these

c ases (1 7 per c ent .) died ; o ne , a m an,act . 45 , became afl

'

ec ted withparaplegia ; a child

, act. 9 m onth s , had severe c onvuls ions ; the o therfour died from syn c o pe, the typ ical fo rm o f death in this affection . In

three o f these four cases , however, there was already existing a chronicdisease (mitral Obstruc tion , granular kidneys bron chitis) . E xperienc eseem s to Show that relapsing fever very rarely pro ves fatal to healthypersons . The p o st m o rtem exam ination o f o ne o f these

0

three c a ses

Showed the presence in the Spleen,which weighed 9 l o f three

fluctuating tum ours c ontaining s an ious fluid, and diso rgan isation o f the

Spleen tis sue .

347) draws attention to Po st-febrile Ophthalm ia a s

a result o f some cases o f relapsing fever. It seem s to have been firs tObserved in Dublin in 182 6

,and in G lasgow in 1843 and 1844 . T he

Ophthalmo sco ic exam ination Of o ne c ase o ut o f 2 0 Sh owed the vitreoussomewhat turbid, with black flo c culi flo ating in it . T he o ptic disc wasindistinc t, the retinal ves sels c o ngested, and the retina o f a dull greyishtint . T he patho logy Of the affec tion is o bscure . N o tes o f these cases

are given .

Ro bins on 187 1 , i , 644) gives an ac c ount o f the o utbreako f relapsing fever, at Leeds , in 1870 . The firs t case seem s to have o c

curred On M arch 3 1 . Out o f 36 1 cases c om ing under no tic e,there had

been in 2 19 previous c ommunic ation with infec ted pers ons . Privationdue to the dis s o lute habits o f the patients them selves o r their parents ,existed in 2 6 1 instan ces . Typhus was said to have attacked the fam ily

with the relaps ing fever, and typho idg which relaps ing fever preses in Leeds during 1870 was

O c to ber) , 13 ; from typhus ,

enteric

s had remarkedo n the relations between interm ittent and relap s ing fever, Senato r(‘B .erl K lin . W o ch .

,187 1 , 3 79 ) gives his own experience o f an

epidem ic in Berlin in which bes ide numero us c ases o f interm ittentand recurrent fever, presented als o s ome case o f a c harac ter betweenthe two . T he patients seemed to be affec ted at first with true recur

rent fever,which later On

,and n o t on ly during the c ourse o f c o nvales

cence, yielded to one o f a regular interm ittent type . He gives six

cases,and c o nc ludes that (1) interm ittent fever supervenes in the

c ourse Of a recurrent fever, at any rate,after the first attack ; (2 ) it

may appear during c onvalescence from the latter ; (3 ) and that it issometimes observed at the end o f epidem ics Of recurrent fever, in dis

5 8 REPORT ON PRACTICAL MEDICINE .

tricts which were fo rmerly free from it . And these fac ts lead him to

believe that recurrent fever sets up a spec ial liability to m alarial p01s oning.

At the same time there is no relation sh ip between the two affec

tio n s on the c ontrary, the fact that one infec tious malady i s no safe

guard against ano ther, pro ves that the two are

.

perfec tly distinct .

Relaps ing fever again m ade its appearance in Londo n ,in N o vember,

1872Lanc et,’ 1872 , i i , attacking eight cases , all in the same

fam ily—three bro thers aged 2 1 , 19 , and 3 , the m o ther aged 40 , and

fo ur sisters aged 16,1 2 , 7, and 5 .

Ins o la tio (Suns tro lce) .

Thin (‘E din .J xvi

, 780) des cribes a number o f cases o f sun

stro ke m et with in Shangha i in 1866 , at a time when the thermometerregistered 96

° Fahr. in the shade . He thinks the attack is no t to be

attributed to great heat alone, but to the glare o f the sun,and pro bably

to an atm o sphere charged with elec tric ity . All the cases c o uld be direc tlytraced to expo sure to the sun

’

s rays falling o n the head o r the nape o f

the neck . The symptoms varied extremely in the wo rs t case c ompletec oma was fo llowed by Speedy death in o thers the c oma las ted only a

few hours, and was succeeded by c omplete reco very ; in o ther ca ses a

tempo rary paraplegia was a c ommo n sequels . Sometimes the attackc o uld s carcely be distinguished from the c ommencement o f a c ontinuedfever. He thinks that the affection is due to paralys is Of the vasom o to rnerves o f the head, and in s ome cases o f the Sp inal c o rd as well .

Macdonald Lancet ,’ 187 1 , ii, 2 89) gives two c ases o f suns troke inmen aged 63 and 34, the first one fatal . His remarks o n the cas es sup

po rt Thin’s views as to the causation of the affec tio n

,bo th a ttac ks

having o ccurred between 6 and 7 p .m .

,no t at the ho tte st part o f the

day, but at a time when the a ir appeared dry, rarefied, and full o felec tric ity .

Clapham (ih . , 1872 , i , 464) publishes the articulars Of a case o fsunstroke reco rded by the patient ” (the writer).

T ire Acute E xantkemata

Ho fmann Zeitschr. f. Paras itenkunde,’

111,

in a paper o n the

rational treatment o f the acute exanthem s,espec ially meas les and

s carlet fever, after stating that it would c o ns ist in the rem o val Of thec auses o f these diseases , the c ontagio us nature o f which

,as Hallier has

c learly shown,c on s ists in the presence Of true fungi, c o ns iders that

latter must be rendered harm les s by the adm in istration o f reme

c apable Of

a s s o on a

typhus (ty


Of smallpox . The disappearance o f the eruption was fo llowed by alamellar scaling ; in the haemo rrhagic case the s cales were an inch

.square . N o sequelaewere Observed. T wo o f the ch ildren died, one o f

very acute nephritis , while the eruptio n s till existed,the o ther, a weak

c hild o f three and a half years , from febrile exhaus tion .

Auchenthaler (ih .,2 2 0) gives a case o f c o inc idence o f meas les and

smallpox in a b oy o f thirteen .

Brunton (‘G lasg. Med. J iv, 2 7) reco rds the fo llowing ca seso f c ombined eruptive disease ; meas les and smallpo x in a pregnantwoman o f twenty-nine ; sc arlet fever and smallpox in a woman o f

fo rty-one, fo llowed by death s carlet fever and varicella in a patient o ffo ur years .

San som ,

“ Case o f prob ab le c o existence of Scarlatina and Vario la ”

(fem ale , act.

3 1 , w ith chart o f tem perature), Brit. Med . 187 1 , i, 395 . Musket, “ Con

currence of Scarlatina and Varicella ”

(c h ild, set. 3 years), ih ., 1872 , i, 7 1 .

S carlet Fever .

Carpenter Lancet ,’ 187 1 , i, 1 10) ho lds that scarlet fever may and

Often do es arise ole novo that it results from inc ipient dec ompo s itio no f the blo od Of vertebrate an imals

,either healthy o r diseas ed

,under

the influenc e o f certain c onditions o f temperature, magnetic state and

m o isture ; that the po ison is probably m o re virulent when pro ducedfrom diseased material ; and that some o f the granules c onta ined inblo od undergo a certain c o rpuscular degeneratio n ,

and are the exc itingagents in the pro duction Of the fever, by altering the charac ter o f the

natural zymo s is which is said to be always pro ceeding within the bo dy .

He attempts to suppo rt this theo ry by the histo ries o f various o utbreak so f s carlet fever in lo calities , hou ses , scho o ls , &c .

,in the neighbourho od

o f places where slaughterho use refuse was sto red o r used fo r manure .

He believes that the disease would be sho rn o f its fatal tendency ifblo od were kept out Of the sewers

,&c .

,in fac t, if a ll s anitary regula

tions were enfo rced. The paper c o ntains an analysis Of the preva

lence o f s carlet fever in Croydon during the las t twenty-two yearsfi"Huber (‘Deut . Viii, 42 2 ):

l

o bserved during an epidem ic o f

scarlet fever in 1869 a haematoma in the neck o f a child, set. 6 . It

appeared as an o va l , indistinc tly fluc tuating tumo ur, o f the size o f a

hen’

s egg, in the left cervica l regio n ,c o rresponding to the c ours e o f

the glands . It had presented itself ten days after the c ommencemento f the sc arlet fever, and had become rap idly larger during the last twodays under the use o f p oultic es . He lo o ked upon it as an abscess ,o pened it, and evacuated abo ut a handful o f pretty firm c lo t, the re

m o val o f which was fo llowed by a stro ng arterial blo od stream ; the

c ase ended fatal ly. He refers to ano ther case o f the same kind, whichhad a m o re fo rtunate result . He thinks that a haematoma may bediagno sed from an abs ces s by the rapid increase o f the fo rmer in a

rela tively Sho rt tim e,and by the c omparatively greater hardnes s and

indistinc t fluc tuatio n o f the tum o ur .

There is an Odd c o inc idenc e b etween the letters used in th is paper and th o seemployed in Pettenko fer

’

s resume’

o f h is writings on ch o lera Zeitschr. f. BioL,’

Bd. v, A . B . S .

SCARLE T FE V E R. 61

J . Harley (‘Med.-Chir. Tran s , lv 103

‘Brit . Med.

1871 , ii , 740) writes o n the m o rbid anato my o f s carlatina and the relation b etween enteric and s carlet fevers . He gives no tes o f twentyeight cases , the maj o rity o f which died on days ranging c onsec utivelyfrom the third to the fifteenth day, and the remainder on the i 7th ,2 o th , 2 9th , 33rd, 4 1 st, and 69th days . Mo re o r less album ino id o r

fatty degeneration o f the kidneys existed in six cases , and in thesedeath o c curred on the 15th i 7th , 2 o th , 2 9th , 4 i s t and 69th days res pec tively . In the rest these o rgan s were healthy . The patho logicalchanges c omm o n ,

with a few exception s (depending on the time o f the

disease) , to a ll , were—1 . The fo rmation o f fibrino us c lo ts in the heartand great vessels during a pyrexial state, at any period o f the diseasethe c omm onest cause Of

o

death during the early stage o f scarlet fever. 2 .

Marked derangement o f the hepatic func tio n as Shown by the deterio ration o fthebile 3 . General inflamm atio n o f the lymphatic system o fglands(o rdinary lymphatic glands , tons ils , and so litary glands o f the tongue,spleen ,

m esenteric , s o litary, From these patho lo gical c o nditionshe thinks that “

febris lympha tica is the app rop ria te s cientific definitionof s carla tina , and he asserts that from this V iew o ne general c onc lus ion as to the c onnection o f s carlet fever and enteric fever is inevitable

,

viz . that the patho logical changes ac c o mpanying an attack Of s carletfever inc lude all tho se o f the firs t stage o f enteric fever, and are s o far

identical with them . When ce it fo llows that the transition from the

fo rmer disease to the latter is no thing m o re than a natural patho logicalsequence, readily determined by any cause which may increase the

intestinal irritation . The writer gives six cases o f the co existence o f

enteric and s carlet fevers , and pro po ses the term abdom inal s oarlatina

,

”already su

ggested to his own m ind in writing the artic le o n

E nteric )Fever, ” in Reyno lds ’ System o f Medic ine,

as the appropriate definition o f a disease whic h every intelligent practitioner wills o oner o r later meet w ith .

”

(T he rep o rt o f thb

e discus sion o n thispaper will b e fo und in the Brit . Med. Jo urn .

’as abo ve . )

Kelly and N o wlan Brit . Med. 187 1 , i , 342 ) rec o rd a cas e

Of severe s carlet fever in a girl , ac t. 3 years , in whom an absc es s wasfo rmed under the angle o f the right jaw,

extending down the neck

and spreading o ver the c lavic le . This o pened spontaneo us ly, and thewho le c lavic le cam e away

,nec ro sed o nly at the acrom ial end. T he

patient reco vered with unimpaired m o vement o f the arm Path .

So c Dublin) .

Meynet Lyon . viii,1 2 4) rec ords the o c c urrence Of s carlet

fever in a child o nly fifteen days Old.

Marchio li,“ So pra di una E p idem ia di Sc arlattina, ” Gaz . Med. Lombard, ’ 1872

109 . Barc lay, “ Ob servation s o n S c arlet Fever, espec ially w i th reference to its

epidem ic character,” ‘St. Geo rge

’

s Ho sp . v, 167. Co pem an ,

“ On ScarletFever, ” ih . , 55 . Chapple, Sc arlet Fever in India, ” Lancet, ’ 188. Cro cker,Iro n in Sc arlatina ,” Brit. Med . J 187 1 , i i , 2 5 5 . Pyle, “ On the Contagio n

o f Scarlatina and Smallpo x,

”ih . , 34 . Aldis , S c arlet Fever fo r T en Y ears

(1860—1870) in the Parish o f St. Geo rge,” London . Hutch inso n ,

“ Case o f RenalRetinitis, w ith pecul iar History as to Scarlet Fever, ” ‘Lancet, 187 1 , i , 4 79 .

Guéneaii dc Mussy ,“ Sur quelques fo rm es graves dc Scarlatina (three cases ),

‘Gaz . des 187 1, 305 . Langier, “ No te sur la Rechute dans la Fievre Scarlatine,” ‘Gaz . 187 1 , 545 .


M eas les (M o rbilli) and Rotheln (Rubeo la ) .

FOSS E din . J xvii , 981) gives a case o f rOtheln o c curring in a

man,aged 2 7 . He defines the affec tio n as scarlet fever c ombined with

catarrh,the catarrh being c o existent and c o etaneo us with the entrance o f

the scarlet fever virus into the bo dy o f the patient, the symptom s o f

the catarrh at o nce showing them selves and aggravating what is usuallythe period Of incubation in s carlet fever.

” His reasons are founded on

the similarity o f the rash and the perio d o f incubation (in rOtheln , 4days ; in scarlet fever, 3 days , with an invas ion perio d o f o ne day) .

Dunlo p Lancet,

’

187 1 , ii , 464) gives an ac c o unt o f an epidem ic o f

ro theln o c curring during the summer m onths o f 187 1 at S t. Helier’s ,differing in no particulars from the affec tio n as generally described .

Fleischmann Zur ROthelnfrage ,” Wien . Med. 187 1 ,

N O . des cribes the symptom s given by vario us writers as characteristic o f ro theln . He thinks that many o f the SO -ca lled tran sitiona lo r m ixed fo rm s may b e explained by the s imultaneo us c ourse o f two

acute exanthem s (s carlet fever and measles) in the sam e patient . Fromhis own Observations he lo oks upon Thomas ’ s “ large spo tted” type o f

ro theln as an urticaria (erythema urtica tum) the “small spo tted” type

he c ons iders to b e a SpeCIfic affectio n ,in which he seem s to lay stres s

o n the absence o f the eruptio n from the face, the absence Of peeling andthe rapid fall o f temperature .

Jacco ud, De quelques Complicatio ns ct Suites de la Rougeo le," Gaz . des

187 1 , 73 . V ézicn ,

“ Rappo rt sur nu E p idem ic dc Ro ugeo le qui a regné pendantles m o is de Février, Mars , Avril, et Mai a Dunkerque, ” ‘Réc . dc Mem . dc Med.

xxvu p . 300 .

Vario la and Varicel la .

It is impo ss ible to do m o re than pick out a few from the verynumerous papers published o n vario la during the two years past ; thebibliography o f the affec tion m ight b e pro longed indefinitely from bo thFrench and E nglish papersfi“Clemens Deut . 187 1 , 2 81 ) des c ribes the cas e o f a girl aged

2 1,in whom the eruptio n was extremely thick on the left half o f the

bo dy, and o nly small o n the right half, espec ially the right face . Onthe third day o f the eruptio n red s po ts appeared o n the right face andarm , o n the fifth day these had bec ome large vesic les o f pemphigus .

One on ly was vis ible o n the right leg . These ves ic les did no t o riginatein abo rted smallpox pustules ; they were sm o o th , filled with yell owishserum

,and healed without leaving a scar.

Simon Arch . iii . supplementing his fo rmer ac c o unt o fthe pro dromal exanthem o f smallpo x (see las t ‘Repo rt,’ p . givesseveral cases in which it was present . From these i t is evident that itS ometimes appears as the very earlies t symptom ,

s o tha t it is po s s ible todiagno se the c om ing affectio n in a patient who exhibits little o r no

fever, and few o r no subjective pains . T he firs t symptom was a sensaw

t io n o f heat o r itch ing o f the abdomen . He refers the charac teristic seatio f this eruption to the axilla ,

and the inner and fro n t part o f the upper

Capt. Butler g ives a go o d repo rt The Great Lo ne Land, Lo ndo n , 1872 .App s

p . 3 17) o f the ep idem ic s Of sm all-p ox am ong th e Indians o f the M is s ouri andS askatchewan, espec ially during the years 1869

-

70 .-A . B . S .

VARIOLA ,AND VARICELLA . 63

arm (the triangle o f the upper arm) . He answers generally in the aflirmative the question whether this eruption is entirely pathognomo nic Of

a c oming vario la ; but he gives two cases in which , though it waspresent , the latter affectio n did no t o c cur, and these lie lo oks upon as

cases Of vario la Sine vario lis . As to its nature, he places the exanthemin the same catego ry a s o ther vas o mo to r neuro ses o f the prodromal stage .

Gubler and Labo rde Gaz . des . 187 1 , 5 2 9) des cribe some Of

the nervine symptoms Of vario la . Frequently there was paralysis o f

mo tion and sensatiomin the lower extrem ities ; paralys is o f the bladderat the c ommencem ent and end o f the affection , s ometimes with cystalgia .

In two c ases there was aphasia in a young woman at the beginning o f

a slight attack , and in a so ldier o n the sec ond day o f the eruption .

Bo th cases rec o vered, in bo th the m o vements o f the tongue wereunaffected, the intelligence was perfec t, and the patients referred to thethro at, which was no t abn o rmally affected, as the cause o f the aphasia .

Cartaz (‘Lyon Mcd.,vi ii

,2 00) gives the results o f an exam ination

o f the brain in 106 cases Of smallpo x, Of which 49 were vario lo id, and13 haem o rrhagic . Of the o ther 44 albumen was present in one out Of

1 2 men , and in six o ut o f 3 2 women . It was present in all the

haemo rrhagic cases . He ho lds that the album inuria o c curs in the c on

yales c ing stage o f smallpox

,and in the maj o rity o f cases lasts on ly a

cw days .

Rommelaere Bull . dc l ’Acad. de Méd. dc Belg ,

’ v . 2 14) writes o n

the relation between vario la and varicella . Ac c o rding to him the po is ono f vario la exhibits itself in three different c lin ical types—vario la ,vario lo id

,and varicella ; person s expo sed to the c ontagion o f varicel la

may take vario la ; and he advises that on an outbreak Of varicellarec o urse Shoul d be had to the precautions employed against vario la(re-vac cination, is o lation ,

He enters into the patho logical changesfound in smallpox. In the cases exam ined by him there were pustuleson the res pirato ry trac t, the vo cal c o rds , near the pylo rus , and in thelarge intestine ; enlargement o f the s o litary glands , sp leen and mesen

terio glands , and Peyer’

s patches ; extravasation in the liver, kidneys ,o varies, bladder and pericardium , &c .

,fatty degeneration o f the liver

and Of the heart mus c le .

Vulpian Bull . de l ’Acad. de xxxvi, 9 1 2 ) dis cus ses the m o de

of fo rmation and s tructure o f the pustii les In smallpo x.

Weigert Centralb l . , 187 1 , 108) has found bacteria in the Skin o f

several patients suffering fro m sm allpo x .

Wyss (‘Arch f. iii, 5 29) has studied fully the anatomy o f

the extravasations in haem o rrhagic smallpox,and purpura vario lo sa

(hfcm o rrhagic smallpo x without pustules ) . T he ha ir and sweat glandsseem to be unaffected in bo th diseases . In the early stages o f smallpo xhe finds that the papules are fo rmed n o t o nly by dis ten s ion o f the cellsOf the epiderm is , but als o by oedema Of the papillae.

Acc o rding to Huchard (Arch . G én . de Med. , m m, death

in smallpo x Is due either to septicaem ia o r a sphyxia . In the latter c ase

the pustules m ay be found extending from the pharynx and larynx,

thro ughout the respirato ry trac t, as far as the finest bro nchi .Revillout Gaz . des Ho p .

’

187 1 , 2 74) prevents the o ccurrence o f


smallpo x Scars by o pening the pustules with a needle dipped in nitrateo f s ilver. He gives the c ase o f a lady o n who se fa c e he o pened all the

pustules but two ; c icatrices were left by these two o nly .

Fox, T he Mortal ity f1om Sm allpo x in regard to Sex and Age,” Med. Times and

Gaz 187 1, i, 538. Breganze, “ Il V ajuo lo E p idem ico nel 1870—187 1 in Milano , ” ‘Gaz .

Med. Ital . Lomb 1871 , 2 2 1, 187 2 , 133 . Dell’

Ac qua, Cenni sul V ajuo lo e sulla

Va c c inazio ne in Milano , ” ih ., 2 5 . Po ppelauer, Reminiscenzen aus den h ies igenStadtischen Po ckenheil -An stalten ,

” Berl. Klin. W o ch 187 1, 2 76. Paul , La

Vario le c ons idérée suw an t les Sexes , les Ages , et les Sa iso ns , ” ‘ Union xi,

2 29 . Grieve, An Analys is o f 800 Ca ses o f Smallpo x,

” ‘Lancet,’ 187 1, i , 3 7 1 .

Y arrow,

“ Repo rt o f Ca s es o f Smallpox adm itted into S t . Luke ’s Wo rkh ouse ,

”ih .,i,

606. Adam s ,“ An in stance o f the Introductio n and Pro pagation o f Smallpox in a

Commun ity, and its E radication by Strmgent San itary Measures ,” Med . Times and

187 1 , i , 1 2 5 . Jones , “ On the Recent Outb reak o f Smallpo x at S t. Geo rge’

s

Ho sp ital, ” ‘St. Geo rge’

s Ho sp . xiv, 2 2 9 . Brouardel , Des co nditio ns do Co ntagio n et de Pro pagatio n de la Vario le, ” Un io n xx, 2 40 . Andho ui, Réfiexio ns

sur la Nature des Vario les ob servés aux Ambulances de Grenelles pendant le S iege deParis, ” Gaz . 187 1 , 180 . G iustiniano , L

’Epidemia V ariuo lo sa del 187 1 inCarpi diModena ,

” ‘Ann . Univ. di vo l . 2 18, p . 13 7. Hjaltelin, Smal lpo x Imp orted into Ic eland by French Fish ing-vesseh , stam ped out by Quarant ine and Sul

p hurous Fum igations , ” Brit. Med . J 187 1 , 11, 5 19 , Grieve, “ Case of Haam o r

rhagic Smallpox, with rem arks , ” ib ., 465 . Gasko in, An tisep tic Treatm ent o f Sm allp ox,

”ib . , 1872 , i, 4 . Baum ler, T he Use o f Baths in Smallpo x,

”ih . , ih . , 45 .

Barlow,

“ On the Exclus io n o f Light in the Treatment o f Smallpo x,

” Lancet, ’187 1 , 11, 9 . Co llie, Lecture o n Smallpo x, ih. , 4 23 . Jones , Propagatio no f Smallpo x, ih ., 28. Gayto n , Haemo rrh agic Smallpo x as so c iated w ith Tetanus

”

(b oy, aet. 17, auto psy), ih . 1872 , i , 187. Cheves , Haem o rrhag ic Vario la ”

(two cases , o ne auto psy) , ib 10 1 . Ducat , A Case o f Malignant Sm allpo x ,

ih . , 79 1 . Aikm an ,“ A Sugges tio n as to the Causes and Treatment o f the Haa

m o rrhagic Type o f Sm all po x ,

” ‘Gla sg . Med . iv, 5 2 . Wo h lrab ,

“ E in Fallvon V ario lo iden m it partieller E nc ephal itis im Gefo lge, ” Arch . (1. xi i i,5 12 . Geissler, E inige Bemerkungen uber Pocken uud Vac c inatio n ,

"ih . , 545 .

S chwenn iger, Kurze No tiz liber d ie Wirkung des Chinins in dem Pro droma ls tadiumder Vario la, ” ih . , 5 7 7. Briquet, Sur la Vario le, ” Bull. de l ’Ac ad . de M xxxvi,858. Guéneau de Mussy, Lecons Cliniques sur la Vario le, ” Gaz . des 187 1,

3 7. Desno s et Huchard, Des Complica tions Cardiaques dans la Vario le , et no tamm ent de la Myo cardite Vari o leuse, ” L

’

Unio n xi, 145 (and c f. Bul l .Gén . de

T . 80 ,Lavisé, Vario le, Dévelo ppement de Ves ic o -

pustules dansle Ph arynx, le Larynx, et les Bro nches , Mo rt, NecrOp s ie,

”Press . Med . 187 1 ,

10 1 . Netter,“ Les Ferments Vario lique et Va c c inale, ” Gaz . des 187 1 , 569 .

Divet, De l’

Action Comb ine’

e de l’

Alc oo l et de l’

Op ium dans le Tra itement de la.Vario le Hém o rrhagique,

”ih .

, 505 . Heine Ueb er die Beh andlung der Blattern und

Abdom inal Typhus , ” Vireh . Arch liv, 195 . E isenschitz , Die Vario la -V aric ellen

frage,” Jahrb . f. Kinderheilk iv, 2 0 5 . Fleisc hm ann

, Ueber Varicella und

V aricellen-Impfungen ,

” Arch . f . i ii, 497 .

Syp hilis .

Lo sto rfer’x‘ (“ U eber die M o glichkeit der Diagn o se der Sy

m ittelst derMikro skop is chen Blutuntersuchung, ” Wien . Med.

1872 , 96 , and in c luded under a paper by o ther wri ters,

Derm . u . iv, 1 15

the bl

The ‘Lancet, ’ 1872 , i . 868, h as a summ ary o f Lo sto rfer’s wo rk .

SY PHILIS . 65

infecting organism s . The two papers c ontain dis cus s ions in which Wed],

Stricker, &c .,to ok part . The latter adds a no te

,in which he says that,

on sending certain test-spec imens to Lo sto rfer, the presence o r absenceo f S philis was pretty generally diagn o sed. Wedl , wh o elsewhereA1 . Wien . Med. 1872 , 46) makes fun o f the who le subjec t

,

declares that he has fo r s ome time found the said c o rpus c les l n healthyas well as in syph ilitic blo o d, and lo oks upo n them as fat cells . Vajda(“ Lo sto rfer

’Sche Syphilisko rperchen ,

” ‘W ien . Med. 1872 ,S . 172 ) impro ved on Lo sto rfer

’

s m etho d by keeping the blo od c on

tinuously m a m o ist chamber. His observations were m ade on the

blo od o f th irty five patients . He describes the c o rpus c les at length,and c oncludes that they o c cur in syphilitic , leuchaemic , and carc inom a

tous blo od m o re frequently than in healthy ; that they are sometimesabsent in syph ilitic b lo o d ; that they are made up o f an album ino id(s . probably a c ompound o f phloretic ac id

,with some c ombina

tion o f an amide,and that they are neither vegetable o rgan ism s no r

fat-cells . Bies iadecki U eber die Lo sto rfer ’S chen Ko rperchen ,

”ib .

,

S . 1 72 ) c omes to alm o st the same c onc lus ions,and says that his c o lleague

Sto pczanski lo oked upon Lo sto rfer’

s c o rpusc les as granules o f paraglobulin .

Owen Rees Guy’

S Ho sp . Rep .

’1872 , 2 50 ) c onsiders that the fo l

lowing symptom s espec ially aid the diagno s is in cases o f cerebraldisease having a syphilitic o rigin . ( 11) The para lytic seizure is generally the immediate result o f some vio lent exertio n

,o r o f s ome long

c ontinued muscular effo rt carried o n to fatigue, and the c o llapse 1S o ftenso great as to threaten immediate dis so lution . (2 ) The hem iplegic o r

irregular in charac ter ; the right arm and

er scarcely affec ted, while the left leg ha so r there may be hem iplegia o f one S ide and anaas

er ; o r lo s s o f sensation may affec t only one limb,

(3) Pain 111 the head and tendernes s o f scalp are

ing. (4) Aphon ia has been o bserved in many c asesHe believes strongly that mercurial treatment is

o f the gumm ous depo s its, and gives three cases

—one with autopsy—in illustration o f his view,which he states as fo l

lows —Syphilitic depo s its may, like various fo rm s o f malignant disease,be present in the brain - substance

,witho ut pro duc ing symptom s

,o r

only slightly inc omm oding the patient . An exc iting cause may intervene and induce inflammation ,

which results in depo s its made up o f the

ordinary c omponents o f the blo od. These are easily ab so rbed by theiodide o f p o tas sium ; the symptoms disappear and the patient is c onsidered perfectly cured. But the original syphilitic depo s it stillremains unabsorbed

,and a recurrence is imm inent, unless rec ourse be

had to mercurial treatment, in o rder to effec t the remo val o f the

gummous mass .

Oser Arch . f. Derm . und iii , 2 7) describes three cases o f

extens ive syph ilitic ulceration o f the sma ll intestine . T he first wasi“ Phloretic ac id is the product of Phloritzin,

a sub stance wh ich o c curs in the b arkof the apple and o ther fruit trees, the compo s itio n o f wh ich is g iven by Strecker as0421124020 41Aq o

—‘ Ao B o S o


suddenly, and thintestinal layers ,caecal valve. In

parallel with themuc ous tissue , a

U nder the m icro scope were foundThe writer enters into the differention ,

tuberculo s is o f the intestines , typho id, and leuchaemia . The two

o ther cases were tho se o f newborn children,and gave the same m icro

sc opic appearances as the first .Simon (ib . , iii, 537) quo tes the views o f several autho rs on the fo l

lowing question s —whether depo s its in the liver (gummata) are s o far

characteristic o f syphilis , that without any further histo ry, o r the

presence o f any c onstitutional affection ,the disease m ay be rec ogn ised

and whether there are cases in which hereditary syphilis may lie latentfo r years , even up to puberty, befo re it is develo ped. In Oppo s ition toDittrich , who answers bo th questions in the affirmative, the autho r c o nsiders them still unsettled. He gives two cases, from his own ex

perience, as matter fo r the discussion o f thes e po ints .

Bradley Brit . Med. J 1871 , i, 1 16) gives the case o f a child,four m onths o ld, in whom a syphilitic eruptio n was ac c ompan ied by thepresence o f albumen in the urine . There was no histo ry o f scarletfever. The eruption and the albumen bo th yielded to mercurial treatment . He fo und

,later

,albumen present in two out o f twenty cases o f

hereditary syphilis , and infers that syphilis may be a cause o f granularo r waxy kidney ; and that the chronic albuminuria resulting from thesechanges Should be treated with small do ses o f mercury .

Lane, Clinical Reco rds o f the Therapeutic Value o f Iodine in the Treatment ofSyph il is , ” ‘Lancet, ’ 187 1, i, 2 67. BerkeleyHil l, “ C lin ica l Records o f the TherapeuticValue of Iodine in the Treatment o f Syph ilis, ” ih . , i , 305 . Buz zard , Clinical Reco rdso f the Therapeutic Value of Iodine in the Treatment o f Syph ilitic Nervous Affec tio n s , ”ib ., i, 339, Lee,

“ On Co ntagion ib .,i, 472 . Berkeley Hill, “ E arly

Syph ilis , ” ib ., 11, 599. Fox (Tilb ury), Primary So re o n the Lip of a Child, ” ih ., i,

536 . Hutch inso n, Report o n Vacc ino -Syphilis , ” ih i i , 143 . S pencer Watso n,

Pto s is, Mydrias is , and Hyperaem ia, w ith Anaesthesia o f the left s ide of the Fac e, i n

a Syph ilitic Patient (fem ale, set. ih. , ih ., ii, 676. Jeaffreson, Syph il itic P tos is


The treatment of the lighter cases c onsists in keeping the parts affec tedfrom the sun ,

and in the severer to apply, night and mo rn lng, an om t

ment c ompo sed o f o live o il, laurel water, and acetate o f lead.

In the chronic fo rm s o f the eruption o c cur Branny desqua

mation o r larger s cal ing o f the epiderm is , taking place no t only as a

c onsequence o f an antecedent erythem a o n the.

expo sed parts, buton the c overed po rtion s of the body also , sometimes extend mg o verthe who le o f the latter, and c onsisting in an hypertro phy o f the

rete muc o sum ,in which the nails a ls o take part . (2 ) Pigmentation

o f the sk in (Lentigo o r Chlo asma) , remaining fo r several years .(3) Cracks in it, extending to the rete muc o sum . (4) An anaemic o r

sallow appearance . 5) Livid spo ts on the lower extrem ities,no tl ced

o nly in women . (6) (Edema o f the skin . (7) A livid c o lour o f the

lips , already no ticed by Strambio in cases o f pellagra . (8) A shagreen

roughness , ac c ompanied by atrophy o f the Skin . (9) Purpura haem o rrhagica , with the symptoms , in s ome cases , o f the haemo rrhagic diathesis .

( 10 ) Lichen milifo rmis . ( 1 1) Separation o f the ep ithelium o f the

muco us membrane o f the to ngue and mo uth,in the wo rst and latest

stages o f the disease, generally acc ompanied by diarrhcea pellagro sa .

( 1 2 ) Onychogrypho sis, partly Spurious , from disappearance o f the fat

under the bed o f the nail,and partly true, from hyperplasia o f the

latter. ( I3) Atro by o f the skin, ac c ompanying general atro phy, inthe last stages o f the affec tion .

Maas (‘Berl . Klin . 187 1 , 363) gives two cases o f SO -calledsporadic pellagra o c curring in children , set . 13 and 15 , who se parentspresented the histo ry o f syphilis .

Gemma La pellagra dei lattanti e dei bambini,

”Gaz . Med .

1871 , 349) describes this affec tion as it o ccurs in yo ung children and in children at the breas t . They present a ro ughnes s o f the skin ,

espec ially on the -fo rearms and checks , with a brownis h c o lo ur, deeing as they grow o lder

,dry and generally livid lips , watery eyes, Igbt

(edema o f the lower eyelid, a red o r pale tongue, with enl arged pap illae.

In addition to s mptom s o f general innutritio n, catarrh o f the bronchi,diarrhoea

,&c .

,t ere is a peculiar form o f dyspnoea, something like that

o f asthmatic patients , vulgarly called bellowing (ma ntesament) o r

wheezing (buffament) by the Lombard women . There may be sleeplessness o r a lethargy, o ut o f which it is difficult to rouse them . In

one case the author no ticed symptom s resembling the delirium pellagro sum o f adul ts . The general cause seem s to be hereditariness , and

,

beyond doubt,feeding with maize . The treatment c onsists o f h

gramme do ses of chloride o f iron in the c o urse o f the day, as 1diarrhoea c ontinues , and afterwards arseniate o f quinine

, c o d-liverwarm baths with chlo ride o f sodium ,

an imal fo o d,with omission o f

maize. E ighteen c linical cases are given in illustration .

Other papers areBillod,

“ Tra ité de la Pellagre, d’apres des Ob servations recueill ies en Italie e

France,”Paris, 1870 . Balardini,

“ Progress i della questio ne dellal ’anno 1855 in Italia e in Franc ia , e c onclus io n i sulla etio logia,et sulla cura di tale m alattia, ” ‘Ann . Univ. di cc xvi i, 70 .

Arsenico nella Cura della Pellagra, ”

LEUCHE MIA . 69

curata c o l metodo Lomb ro so in To rnaco , ih ., c cxvi, 5 59 . Stramb io ,“ Intorn o alla

cura della Pellagra, ” ih ., 1 7 . Cristina , Pellagra c on T ub erculo si curata co ll’ Ac ido

Arsenico so ,”ib ., 190 . Manzin i and Dotti, Dell Arsenico nella Cura della Pellagra

e della Paz zia ,” ih . 69 ; and see a very lo ng paper by Lussana Sulla Cause dellaPellagra), ih 1872 , 35 1 , w ith discuss ions o n the same by Balardini (ib ., 189) andLom bro so (ih ., 2 2 1, Lombro so , Studi Clinic i ed E sperimentale sul la Pellagra ,Bo logna, 187 1 .

L euckwmia .

Salkowski (‘Vireh . 1,174 , and 111, 58) has made some curio us

clinical researches into Neumann’

s case o f unc om plicated leuchaem ialienalis (cf. Neumann ,

‘Arch . d. xi, In his last c ommunica

tion he gives the fo llowing analyses o f the urine ; its quantity varied,in the c ourse o f ten days, between 560 and 1440 cubic cm . T he

propo rtion o f urea varied between 104 2 and 2 72 grm S . ,averaging

193 58 grm s . The proportion o f uric ac id varied between 6 46 and

5 ; its mean Its proportion to the uric ac id was 1 : 17 4 ,showing marked increase in the amount o f the latter. A little albumen

was always present . There was no lactic ac id Slight traces o f form icand o ther vo latile ac ids . The author, in c onc lusion , draws attention to the fact that Leyden has several times tried galvano -

pune

ture o f the Spleen, with the only result o f causing its temporaryenlargement .Reincke 187 1 , 2 2 2 ) gives the appearances found p o st

mo rtem in a patient suffering from advanced leuchaem ia lienalis . The

retina was beset with numerous small haemorrhages, increas ing in

number towards the periphery. These were rounded and prominent,and present in all the layers o f the retina . Red glo bules o c cupiedgenerally the outer po rtion ,

and white cells almo st alone their c entres .The Optic nerve was no rmal . He c onsiders that there is, in these cases,a simple extravasation o f leuchaemic blo o d, and does no t agree withLeber in lo oking u on them as lymphatic new growths .

Wo od Amer. ourn . o fMed. Sc ience, ’ lx11, in a paper on the“ Relations o fLeuc o cythaem ia andPseudo l eukaemia

,

”desires to show that

there is a third fo rm ”o f the latter disease

,a sp lenic variety, which he

thinks has been fo rmerly described under the names o f tum ours o f theSpleen, splenic cachexia

,& c . , and he gives the fo llowing case , which

he ho lds is suffic ient to pro ve the po int . A man,act . 30 , serving in

the army in Virginia during the rebellion , had suffered severely fromcamp-diarrhoea o r dysentery . In 1870 he was taken with a draggingand heavy pain in the back and left side, believed for the next two

months to be rheumatism . During the suc ceeding two m onths herapidly lo st flesh and strength , and in August came under Observation .

He was then very thin and weak, though able to walk ; the Skin was

pale, the abdomen enlarged, spleen and liver extremely so,with Slight

(edema o f legs there was n o in crease in the white cells . In O ctoberhe died. The Spleen ,

at the autopsy, was eight inches long, five and

three quarters bro ad, and nearly four thick ; the liver was also muchenlarged ; the lymphatic s o f the thorax, abdomen

,and axilla were much

increased in size . The writer pro ceeds to discus s the question whetherthere is any change in the marrow of the bones peculiar to leuco cy


thesmia,and gives three o ther cases , which presented hyperplasia o f the

medullary cells .

Wa ldeyer, “ Diffuse Hyperplas ie des Kno chenm arkes, Leuk ‘

amie,” ‘Vireh.

111, 305 . Neum ann , Kernha ltige Blut-zellen b ei Leukam ie und bei Neugeb o renen ,

”

Arch . d . xi i , 187. Id Ein neuer Fall vo n Leukaem ic m it E rkrankung desKno chenm arkes, ” ih., xiii, 48 1 . Mo sler, Die Patho logie und Therap ie der Leukamie, ”Berlin, 1872 , 2 83 (reviewed Deut. ix, E ames , Case o f Leuco cythaem ia,‘Dub l . J li , 388 Brit. Med. J 1871, i , 653 . Ward ,

“ Leukaam ia Lym

phatica (man, act. 24, w ith auto p sy), Lancet, ’ 187 2 , i, 5 77. Patchett, Leuco cythesm ia, great hypertrophy o f spleen, c o ns tant depo s it o f uric ac id in urine (woman,act. 2 3, death from fractured b ase o f skull, autop sy), ih . , ih . , 682 .

M oro cytkemia .

Under the termM orocytkemia , V anlair andMasius Bull . de l ’Acad.

Med. Belge, ’ v, 5 15) describe a m orbid state charac terised by thepresence in the blo od, in considerable numbers , o fred cells (m icro cytes) ,distinc t from the o rdinary blo od-cells . One case

,that o f a yo ung

woman attacked so on after her firs t c onfinement,is given in full, and

the paper,which enters at great length in to the symptoms , the exami

natio n o f the blo o d and urine,&c . ,seem s to b e based upon this case .

The symptoms are described as pains o ver the epigastrium and Spleen ,

hypertrophy o f the latter, atro phy o f the liver, remittent jaundice , tempo rary aphonia, and paralysis o f the limbs . A sister o f the patientwas said to have presented the same train o f sympto ms some yearsprevio usly .

P rogressive Muscular Atrop hy P seudo -Mus cular Hyp ertrophy .

Martini Zur Kenntnis s des Atrophia Mus culo rum Lipomato sa ,

187 1 , 64 1) has examined the musc les o f a patient whodied o f this affection

,bo th in the fresh state and after hardening in

chrom ic ac id . He o bserved in the striated subs tance ro und o r o va lfissures , at firs t small , which '

either had a central po sition, singlyfo rin pairs , o r were distributed o ver the transverse section o f the prim itivebundle to the number o f ten o r twelve . T he fis sures increased fromatro phy o f the striated subs tance o r the unchanged septa , till at las ttubular fibres, analogous to the musc les o f insec ts , were fo rmed. Theirc o ntents c o nsis ted o f a homo geneo us pro toplasm ic mass (serous, as

o ppo sed to s imple atrophy) . This o bservation dispo ses o f the view thatIn progressive lipomato s is no o ther change takes pla ce but increase o r

decrease in thicknes s o f the muscular fibres . The same change (serouso r tubular atro phy) is found to take place in o ther cases, in which themusc les become atro phied through pressure o f new and growing tissue(fat, sarcoma) .

E ulenburg Vireh . liii, 36 1 ) rec ords three cases, in which the

affection first Showed itself in three s isters suc ces s ively in the eighthyear o f their age. They were the o nly children o f healthy parents , whodo n o t seem to have presented any hereditary affection ,

and were themselves quite well up to this period. He gives a full ac c ount o f the cases ,and c ompares with them the repo rt by Meryon Gaz . des 1854,N o . I 2 7) o f the o c currence o f the affectio n in fo ur bro thers , and ano ther,

MUSCULAR ATROPHY . 71

by his own father Deut . in two bro thers . He believesthat the patho logical o rigin o f the disease must be lo oked fo r in somecongenitally defec tive fo rmation o f the centra l nervo us system , probablyin the cells o f the grey substance o f the Spinal c o rd.

Vogt Berl . K1in . 187 1 , 2 65 ) c ontributes a case ofprogressivemuscular atro phy . The patient, a man , had lived a hard life

,and had

suffered from ague and a severe attack o f typho id. The disease hadno t made any advance fo r the last year and a half. T he treatment c ons isted o fgo o d nutrition . He gives a summary o f seventeen cases o c curring in the period 1863 -7 1 . Of these

,thirteen were men, two women ,

and two children . He refers the o rigin of the affec tion to severe labo urin the majority o f cases , to expo sure to c o ld and wet, and in two casesto typho id and ague . Generally speaking, the musc les o f the ball o fthe thumb were first affected, then the delto id, biceps , triceps, &c . The

same rule seem s to ho ld fo r the frequency with which these musc lesare attacked separately. The abdom inal musc les and the diaphragmwere no t affected in any case . N o case impro ved ; one o nly wasstationary .

Gombault Arch . de 1872 , iv , 509) publishes a case ofpro

gressive muscular atrophy, ac c ompanied by glo sso -labio -laryngealparalysis

,in a woman

,act . 58, under the care Of Charc o t . T he autopsy

Showed pigmentary degeneration o f the nerve-cells o f the hypo -

glo ssalnuc leus in the m edul la o blongata , &c .

,sc lero sis o f the anterior pyramids

and antero -lateral c o lumns ; disorganisation o f the anterior grey substance in parts

,yellowish c o lour o f the musc les o f the face and upper

extrem ities, many o f the fibres having lo stP'

their transverse striae andundergone granular degeneration . The case Confirmed the c onnec tionalready po inted out by Charc o t, between rigid c ontrac tion o f the jo ints

,

which existed in this case and s c lero sis o f the lateral c o lumns o f the ‘

co rd (and see Gaz . Med.,1872 ,

Kno ll Wien . Med. J 1872 , s . 1) describes a case o f paralysis

pseudo -hypertro ph ica in a b oy aged 13 years . He was the only child o fealthy parents, and no histo ry c ould be obtained o f any fo rmer affection .

The musc les o f the lower extrem ities and the lower po rtion o f the trunkas high up as the last rib

,were much enlarged, while tho se o f the upper

art were o f the normal s ize,and espec ially showed no signs o f atrophy .

he apparently hypertrophied mus c les were no t weak and flabby, as

o ther o bservers have no ticed, but tough and hard. This c ondition wasexplained by the m icro scopical exam ination o f a portio n o f musc leexc ised from the left gastro cnem ius . The mus c le fibres were found tobe separated by bro ad tracts o f fibro us c onnective tis sue

, po or in cells,

and interpersed with fine nuc lei . This interstitial tissue c ontained nofat

, either in the fo rm o f cells o r drops . The fibres them selves Showedmarked diflerences in their diameter. The majo rity o f them were o fmoderately no rmal c alibre some were les s than the normal, o thersagain exceeded it c on siderably. No relation c ould be made out betweentheir size and that o f the mas ses o f interlying connective tissue . The

transverse and longitudinal striation o f the fibres was well preserved,b ut delicate, and the distance between the fo rmer unusually small .Separate fibres

,espec ially the thicker ones, o ften Split up into two equal


parts

. (T o Show that these appearances were no t due to any mo de of

preparation

,he made vario us c omparative researches on muscle from a

b oy who had died o f acute inflammation o f the lungs .)T he musc les examined Showed no granular o r fatty appearance . He

refers to o ther investigatio ns in cases o f progres sive muscular atro phy,in which a s imple , n on -fatty degeneration o f the fibres has been found,and he thinks that upon these grounds a sharp distinction between thetwo fo rm s o f disease can b e drawn . He believes that the c onnectivetissue induration o f the mus cle represents an earlier Stage o f the affec

tion ; that the fatty infiltration o f the musc les , like the lipomato s iso c curring after the divis ion o f nerves, is one stage o f the same pathol ogical disease . But the development o f fat is no essential sympto m o f

the affection , and Duchenne’ s name o f paralysis pseudo -hypertrophicais

,therefo re, still the m o st c onven ient . The affec ted musc les reac ted

with a weak induction -current as healthy ones : with a stro ng current,

only feebly, and without power o f lo c omo tion . A long disquisitionsuc ceeds on the c ontractions o c curring in paralys is pseudo -hypertro

ph io s , and o n the secretion o f urea . As to whether the disease be a

primary affec tion o f the musc les , o r due to an affec tion o f the centralnervous system ,

he thinks c anno t as yet be dec ided.

Duchenne Gaz . des 1872 , 634) publishes a no te o n the patho ~

lo gic al anatomy o f pseudo -hypertro phic paralysis in five m o re cases ,which only co nfirm his former researches .Barth , Beitrage zur Kenntn iss der Atroph ia Musculorum Lipomatosa

44, autop sy),‘Arch . (1. Heilk ,

’xi i, 1 2 1 . Tillaux, Atro phie Mus culaire

aux Co ngélations, ” ‘Bull . Gén . de t . 80, p . 2 26. Banks , On

Muscular Atro phy (three c a ses , o ne death ,187 1 , i , 2 . Pepper, Clinical Lec ture o n a

Philadelph . Med. Tim es ,’187 1 , i, No . 18 (q

E iri Fall von wah ren Muskelhypertro ph ieDown ,

“ Case of Para lys is, w ith apparent

Progress iva, e Storia Clinica di uno cas o della stessa,”Gaz

Butlin , Condition o f the Musc le in Pseudo -HypertrOph icBarth . Ho sp . vii i 1 24 . Greenhow ,

“ Case o f

Atrophy, ” Clin . SOC. v 2 10 . Davids o n, On Pseudo -H

fluscular Paralys is ”

(three cases, with ph o tograph s, Glasg. Med .

9.

Diabetes .

Zimmer Die Na chste U rsache des Diabetes Mellitus Deut .1871 , 4 1) quo tes the experiments o f Bernard

,Pavy, &c . , to show

that the pro duction o f sugar from glyc ogen is increased in the liver bygreat c ongestion ,

in the musc les by c o ntraction,and in the who le body

by large venesections . The m ode o f wo rking in all these cases he findsIn the larger am ount o f water acting as a ferment upon the glycogen o f

the different o rgan s . The same pro ces s o c curs in artific ial diabetes , o nlyin larger amount and fo r a longer time . In Bernard’s experiment ofpricking the flo or o f the fourth ventric le

,in divis ion o f the splanchnic

nerve, in destruc tion of the upper cervical ganglion , o r extirpation of

DIABETE S—RHEUMATISM . 73

the so lar ganglion (Klebs) , the same result o c curs . In all there i sparalysis o f the c ontractile elements of the blo o d-vessels in the liver ;and in all these he sees the same action o f the water, the same fermentation o f the glyc ogen ,

the same swelling o f the liver cells,which he

believes to be at the bo ttom o f what may b e distinguished as two form sof artific ial diabetes , the one produced by paralys is o f the vessels

,the

o ther by changes in the nutrition o f the cells,o f the liver. In the same

way he explains the o c curren ce o f diabetes in men . In autopsies o f thesecases the liver is frequently found filled with blo od.

Salinger (‘Beitrag . zur Diagn o se des Diabetes Mellitus,

’ih ., 306)

ho lds that the nature o f a disease is identical with its seat in any givenorgan to which it m ay be referred, and, therefo re, the muc ous mem

brane o f the digestive o rgan s is the o riginal seat o f diabetes . So longas arterial blo o d c ontains no sugar, none can b e abstracted by any o f

the o rgans , nor, consequently, taken up by the veins o r lymphatic s .

If, however, sugar be found in the vena cava and right ventric le, itmust have entered by the tho rac ic duct and the cap illaries o f the

Small intestine ; c onsequently the intestinal mucous membrane is theonly seat o f the formation o f sugar (l) .

Kratschmer (‘W ien . Med . 1871 , NO . 8) concludes from his

researches into the action o f opium and m o rphia in diabetes,that

patients affected with this disease easily bear large do ses o f Opium ; and

that no t only is the sec retion o f sugar c onsiderably dim inished by thedrug, but even arrested for a shorter or longer period. The same resultfo llows the use o f m o rphia .

Donkin, The Skim -m ilk Treatm ent of Diabetes and Bright’ s Disease, w ith Clin ic aOb servations o n the Sym ptom s and Patho logy o f these Afl

'

ections ,” Lo ndon, 187 1 ,

pp . 3 1 7. Bouch ardat, E aux de Vals dan s la Glyc o surie, ” ‘Gaz . des 187 2 ,I

4 2 1 . Duboue,“ De l

’Odeur Ac ide de l ’Haleine c omme s igne Diagno stique du Dia

bete , ib . , 80 2 . Salom on, “ Gesch ichte der Glyco surie vo n Hippokrates bis zum

Anfange des 19 Jahrhunderts ,”Deut. viii , 489. Sedgw ick, On Tempo rary

Glyco suria as a sequel o f Ch o lera , ” ‘Med.-Ch ir. liv, 63 . N ico l, “ Case of

Diabetes Mellitus under Milk-treatm ent : death”

(boy, set. I 5 , the autopsy showed

slight atherom a o f the aortic valves and aorta, fatty liver and (prob ab ly) kidneys ,slight m ilkiness o f the arachno id, o ther organs norm al), Brit. Med . J 187 1 , ii,64. Sm ith , “ Case of Acute Diab etes , with Clin ical Rem arks ”

(boy, act. 16, no

autopsy), ih ., ib . , 728. Donkin, Further Ob servations o n the Skim -m 1lk Treatment

o f Diabetes Mellitus, ” ‘Lancet, ’ 1871 , i, 603 . Pyle, Cases (two ) o f Diab etes, ” ib1872 , i, 7 18. Balfo ur, On the Treatment o f Diabetes by Lactic Ac id (seven c ases),Edin. J xvn , 533 . Guéneau de Mussy, Etudes sur la Traitement de laPo lyurie,” Gaz . des 1871, 389.

Rheumatism.

Ferber Arch . d. xi i,80) gives the further history and

autopsy o f a b oy who se case he had already reco rded (see last Report,’p . The patient suffered from j o int-affection, cho rea and heartdisease. The attacks o f rheumatism were repeated frequently, ac c ompanied by a c luster o f enlarged cervical glands , such as o c curs in Spinalmeningitis . The brain and Spinal c o rdwere no t examined the pericar

dium: was c ompletely adherent the valves were defic ient,and the

muscle fatty . He gives a case of the same kind still under treatment .The patient was a b oy o f two years and eight m onths, who se father


had had rheumatism,and who se grandfather had suffered from convul L

s io ns and paralys is . In May and September o f 1868 the child had hadtwo attacks o f eclamps ia . In April, 1869 , there was swell ing o f bo th hisfeet, with fever. This was fo llowed by cho reic m o vement o f the handsand face

,and head symptoms . By the end o f May the child was c om

pletely well . The same attack o c curred a yearlater, and at this timca rasping murmur was heard o ver the heart, d1sappear1ng s o o n afterwards . The patient was well again by the m iddle o f May . T he autho rlo oks upon this case as one, no t o f S imple articul ar rheumatism ,

but o f

men ingeal affection .

Andrew Clin . So c . v . 2 29) gives the ca se o f a b oy, ac t. 16,

in whom a wide daily range o f temperature in rheumatism was a s soc iated with disease o f the heart, vegetations on the m itral valve, andinfarction o f the spleen .

Handfield Jo nes Lancet,

’

187 1 , 11, 636) gives a summary o f fiveca ses o f acute rheumatism ,

treated with drugs . He c o nc ludes that theaffection has no fixed perio d o f c ontinuance, but is on the co ntrary subjectto very considerable variation s . These , he thinks , depend on the qua lityo f the individual system , by which also the cho ice o f remedies shouldbe guided. He gives alkalies in cases where the urine and sweat areac id ; where the pulse is small and the patient weak the are injuriousin such c ases quinine in full do ses 18 very o ften o f

ygreat service .

Blisters , which are valuable agents in relieving pain ,do no t curtail the

c o urse o f the disease ; in some cases they add to the nervo us irritability . Purgatives sho uld always be given at the o utset

,and when the

tongue is foul, &c . The subcutaneous injec tion o f atro pia is generallythe best remedy fo r the pain .

Fo ster Brit . Med. J 187 1 , 11, 72 2 ) gives an ac c ount o f articularpains

,resembling in a ll particulars tho se o f rheumatic fever, Observed

in two diabetic patients , to whomE smarch Berl . Klin .

till all the symptoms o f acuterec ords four cases in which it was

Ro th V irch .

autopsy o f a pig,seized with lo s sca lled m alignantthickened ; vegetations were present o n the o ther threebo th hip -jo ints , the right knee , and left Sho ulder-jo intfluid, and thickened and hyperaemic syno vial membranes .

endo carditis c ombined with recent inflammation o f the jo intsfi"

Might th is not b e a case o f pyaem ia —A. B . S .


with espec ial reference to the pause in the development o f the teeth.

On the average a m onth , to a m onth and a half, o c curs between the

appearance o f the several in c is ors , and two , to two and a half m onths,

between that o f the several can ine and back teeth ; s o that the twentym ilk teeth are appearingafter the eruption o f th

teeth,the first symptom o f rickets is shown in t

to o th development . This is fo llowed by the o therlater teeth are out before they are fully fo rm ed.

Grunhut and Jay, Three Cases of Ra ch itis in Ch ildren ,

” Am er. Journ . Of Obstet ,

187 1 (August), p . 3 1 7. Parry, Rach itis (c ase o f co loured boy , ac t. 9 m o nths ,

w ith auto psy) ,‘Am er. Journ . Med. lxi, 4 2 7. Id. , Ob servatio ns o n the

Frequency and Sym ptom s o f Rachitis , w ith the Results o f the Author’s ClinicalE xperience, ” ib .

, lxii i , 1 7,

Addison’

s dis ease.

Laschkewitsch publishes Wien . Med. 187 1 , 42 5) the fo ll owing z—A strong and well-no urished suffered from excessiveweakness ,palpitation ,

the muco us membrantous . His red blo od

The patient’

s condition impro ved in the co urse o f a m onth underthe numerical pro po rtion o f the red cells increased theyintensely co loured

,but still retained the capability o f undergo ing

in form . Three months later the patient returned with bronzeation o f the face

,neck

,nipples , scro tum &c .

Tuckwell St. Barth . Ho sp . Rep .,

187 1 ,Addison ’

s disease in a woman act . 3 1 , with a fullm o rtem exam ination and the m icros cop ic appc apsules . The latter were enlarged, hard and

toughly fibrous , with a dull white surface studdedSpo ts .supra-r

nerve .

elusion on the nature and patho logy o f this disease agrees

mo st E nglish writers on the subject.

Payn e Path . So c . xxii,2 81) records a case

disease in a man act . 3 2 , in whom the s o ftened andcap sules were ac c om panied by a so o ty c o lo ur o f th

any rate to any perceptible degree, and by a dep o s itc onnec tive-tis sue cells o f the pia mater c o vering the In

and first two or three inches o f the medulla spinalis .G illiam , Identity of Addiso n ’

s Disease and Degenera tion o f the Gas tri‘Ph il . Med. Surg . 187 1 , xxiv, 473 . Church ill, E ffects o f E ther

the Skin in Addison ’s Disea se, ” Path . So c . xxii, 3 1 7. Quain

if Cf . last Bienn ial Repo rt, ’ p . 87.

ANIMAL “‘

PARASITE S . 7 7

Addison ’s Disease (man , a t. 24, c ap sules cretified), ib ., 2 80 . Finlayson , On a Case

of Addison’s Disease ”

(m an, wt.

‘G lasgow Med. J iii, 433 . Marshall,Case o f Bronzed Skin , chro n ic disease ‘

o f the m emb ranes of the b rain , p erforationo f the skull, ab c es ses o f the sc alp , death

”

(m ale, act. 63, autopsy), ih . , iv, 3 5 5 . Mo ore,

Case of Bronzed Skin w itho ut Disease o f the Suprarenal Cap sul es , ” Dub l . Quart.li, 80 . Rus sell, Hereditary Bronze Co lour '

Of the Skin s imulating Addison ’

s

Disease, ” ‘Med. Tim es and 187 1 , i, 5 7 . N icho lson , Addison ’

s Disease”(boy, set. 14 , autopsy) ,

‘Brit. Med. 1872 , i i, 1 2 1 . Merkel, E in Fall vonBronce-Haut ohne Neb ennieren -erkrankung," Deut. x, 2 0 5 .

E xophtha lmic Goitre.

Galezowski (“ E tude sur le go itre E xophthalmique,

”Gaz . deS .

1871 , 42 5) gives a general sketch o f the affec tion ,c laim ing for

Dem ours the first description o f it in 1818. He c ons iders the affectionto be a nervine one

,ac companying les ion Of the sympathetic nerve,

such as Lancereaux and Peter found in one c ase in the hypertro phyand hyperaemia o f the inferio r c ervical ganglion . He th inks the protrusion o f the eye is due to the c ontraction o f the small musc les inTenon’ s c apsule, supplied by that nerve .

Emmert (“ Histo rische n o tiz iiber Mo rbus Basedowi, neb st Referat

fiber 2 0 selbst beobachtete Falle dieser Krankheit,

” Arch . f.

xvii,2 03) gives the first description to an E nglishman Co l

lections from the unpub lished writings o f the late C . H . Parry, ’Meyer Berl . ‘ Klin . 1872 , 468) gives four cases o f this

affection in females in which go od results were obtained by galvanizingthe cervical sympathetic .Hutch inson ,

“ Cases of Basedow’s Dis eas e ”

(four fem ales) , ‘Lancet, ’ 1872 , i ,538. Patchett,

“ E xophth alm ic Go itre, unusual severity of symptom s, ulc er of

c ornea, cured”

(woman, act. ih ., ib ., 82 7.

Anima l P arasites .

Udb c Vireh . 111, 439) gives a table showing that of 1 I

pigs killed in the duchy o f Brunswick, from E aster 1868 to 1869 , six

only were found to have trichinae. Petri (ib ., 440) gives ano ther table

of al l the pigs (5688) s laughtered at Ro sto ck in 1870 : one o nly wasfound affec ted (of. las tIn the Sec ond Annual Report o f State Bo ard o f Health in Massa

chusetts ’ (187 1) m ay be found (p . 46) a repo rt on Trichina Diseasein Mas sachusetts . ” The history and symptom s o f the affection are

given , and an account o f outbreaks of it in 1870 , one in Saxonville and

the o ther in Lowell . In the first,three out o f a fam ily o f Six, who had

eaten underdone fresh fried pork , were attacked, two boys, set. 14 and

I9 , and their Sister act. 1 7 . The eldest b oy died with symptoms o fphoid fever. In the second case—badly repo rted—a m o ther and fo ur

c dren ate portions o f raw sm oked ham (i. e . no t even s lightly c o oked,as the father to ok it) and became affected. Living trichinae werefound in fragments o f the ham exam ined. AS to prevention—a tem

perature o f 150°to 160

° F . is fatal to the trichina . Pickling may anddoes probably render the po rk harmless, smoking do es no t. Unco okedpork musc le, 13. e. the lean portion (fo r trichinae are not harboured inthe fat) , can never be eaten with safety .


Kittel Wien . Med. Zeitung, ’ 187 1 , 2 54) describes an epi

trichina disease at Libau in Saxony . Over 90 peo ple werewith very severe symptom s after eating the flesh o f a diseasedsausages made from it .o b served in the eyes . Tat any rate at first, perfectly free m o vement o f the eyeh

decreased as o ther symptoms o f the presence o f the

musc les o f the eye showed them selves . S imultaneously o ccurred

nate mydrias is, which the autho r refers to paralys is o f the third(the Short ro o t Of the c iliary ganglion) .

Maurer E ine Trichino sisgruppe aus Bayern,

” Deut . Arch368) gives an ac c o unt o f an o utbreak o f trichino sis , rare in the

E rlangen) . In o ppo s ition to the vrarity o f the affection is due to the smto the rare o c currence o f affected pigs . The latter is co ntradic tedfrequent o c currence o f trichinae in rats . In o ppo s ition

,to o

,

views o f Leuckart, Pagenstecker, and o thers,he c ons iders

an imals as affec ted sec ondarily, and as a co nsequence o f affec tedthe same neighbourho od. From materials gathered in Saxony, BWiirtemberg, and Austria , he deduces certain averages as to tqueney o f trichinae in rats .

doubt the truth o f Kiihn’

s ob

eaten by pigs .

* T he autho radvice whic h may c onduce to the prevent ion o f trichino sis amo ngReeb (‘Rec . de Mém . de

datids o f the brain,the first in a boy ac t. 5 years , in whom

m arked symptoms were a left-s ided cho rea , and affec tions o facc ompanied by dilated, unc o ntracting pupils , and atro phy o fnerve . A prom inence was gradually develo ped o n the righb one

,b

o n the

tents .remo ved the first time

,and seventy the sec ond

tetanic character set in some time befo re death .

fo und three c ommun icating cysts,o ne sub cut

between the bone and the dura mater,and the

The taste o f these animals is as varied as that o f the

them . T he p igs o f E strem adura are sa id to eat lo c usts ;Murray

’s Handb o ok fo r Spa in ,

’1869, part ii , p . the

his p igs in p lac es ab o unding in vipers, o n wh ich they fa

jamb ons vermeils the Due de St.“ Ces jamb ons o nt nu parfum si

est surpris il est impo ss ib le de rie1871 , ii, 394) draws attention to

the hogs of America and Australia—A. B . S .

DISEASE S OF THE NERVOUS SY STEM . 79

po sterio r lobe o f the right hem isphere, surrounded by a th in layeronly o f brain substance . This further c ommun icated with the lateraland middle ventric les , and term inated in a vast pouch in the p o sterio rlobe of the left hem isphere . Numero us hydatids were found thro ughout the cavities . T he who le brain

,inc luding the central ganglia, was

mo re o r les s so ftened. T he s ec ond case is that of a b oy, act . 18,who

after frequent attacks o f interm ittent fever suffered from acute suprao rbital neuralgia . Hem ip legia, fo llowed by c oma

,o c curred, and four

days later he died. Po st-mo rtem,the who le right hemisphere was found

to be destroyed by a large cyst filled with hydatids . As in the fo rmer

case, it was surrounded by a thin layer of brain substance, but wascompressed by the Skull bones .Zuber (‘Gaz . des 1872 , 730) rec ords the o c currence o f two

hydatid cysts in the lung o f a man, aged 2 2 . The symptom s were tho seof acute tuberculo s is . Rupture o f one sac to ok place into the pleura ’

and was fo llowed by death .

Hirschberg Berl . Klin . 1872 ) remo ved cysticerc i from the

eye o f a woman and o f a b oy .

The Lyon Med.

’

(x, 34 1) quo tes a case rec o rded by Armour

(‘Detro it Review o f in which po rtions o f taenia so lium werepassed by a child three days o ld.

Dickinson , Three Cases of Trich inias is after‘

E ating Home-fed Pork, ” ‘Brit.Med. J 187 1 , i , 446. Huber,

“ E inige No tizen uber E ch ino co c cus Mul tilo cu

laris , ” ‘Vireh . l iv, 2 69 . Fromm ann ,

“ Zur Casuistik der Trich in iasis , ” ih. ,

liii , 50 1 . Fagge and Durham ,

“ On the E lectro lytic Treatment o f Hydatid Tumoursof the L iver, ” ‘Med.

-Ch ir. liv, 1 . Giraud-Teulon,

“ Cysticercus Ladriq ue(C . cellulo sae) dans le c o rps vitré, ” Gaz . des 1872 , 1 2 . Surmay, Ténia Mul

tiple, ” ih . , 900 . Leidv, Taenia c aused by the use o f Raw Beef (T . medio -canellata) ,‘Amer. Journ . Med. lxu , 293 . Presto n,

“ A Lumb ricus discharged through an

Ab scess ab out the Hip -jo int ”

(boy, act.

‘Lancet,’ 1872 , i i, 777. Welch , “ The

presence o f an E ncysted E chino rhynchus in Man ,

”ih ., ih ., 703 .

Veyeta ble P arasites .

Richter (‘Zeitschr . f. iii,I ) finds

,on examining the

central po rtion o f warts,an extremely large number o f m icro c o c c i in

and between the epithelial c ells , and on plac ing them in a So lution o f

ammonia and sugar Obtains numerous and largely branched mycelia .

Hallier Des Paras iten deS Infections Krankheiten,

”Zeits chr . f.

ih . ,15 7) publishes the results o f his experiments on the

fa ces o f sheep whic h died o f fo o t-and-m o uth disease .

Tuckwell St . Barth . Ho sp . viii,1 2 5) writes on the ringworm

of cattle and its c ommun icability to man .

13. Disea ses of the Nervous Sys tem .

Hys teria .

Charc o t Gaz . des H6 187 1 , 556) gives a lecture on two ca ses o f

sterical c ontraction o f t e limbs , o ne, a woman aged 40 , representinghe paraplegic


Jam ieson (‘E din . J xv11, 2 9) gives a case o f“ trance in an

hysterical girl, aged 16 years .

In a c linical lecture on suppo sed cases o f hysteria , Fuller (‘BMed . J 187 1 , 11, 6 10) draws attention to the nec essity o fc arefully all the symptoms , and mentions two ca ses o f su

hypo chondriasis or hys teria , in which the symptom s duringimmediate cause of death, were due in one case to abscess Of the bra iny.in the o ther to a small aneurism causing ero s ion o f the Spine .

Tilt (ih .,ib . ,

690) attacks the views with regard to hysteria held “ bymen who own they know no thing about diseases o f women ; quo testhe o pinion o f Chambers , Russell Reyn o lds, and Handfield Jones , &c .

,

and think s that to unders tand rightly hysteria , cata lepsy and epilepsy,the diseases o f the ganglionic nervous system

”should be studied.

Ro senthal (“ Ueber vasom o to ris che Innervatio ns stiirungen bei Hysteric , ” Wien. Med. 187 1 , 182 ) reco rds a fresh case o f

analgesia with no lo ss o f the sense o f touch , in an hysterical girl . He

refers to the fact that in hys terical patients the anaesthesia and analgesiaare regularly distributed ac c o rding tofthe limits o f cutaneous nerve-terri

and c onvulsions .a quarter to half an ho ur . On the return o f

and temperature ro se again ; there was po sitivfeeling o f warmth , redness o f the nails , and

T he time just before these attacks was markedwas rarely no ticed on days which werein various parts o f the trunk , mo re frequently on the left than tside sometimes in the left upper and right lower extrem ity .

o nset and term ination o f the attack there was anaesthes ia .

m o vemen t c ould be exc ited in the hands and fingers , while the

reco very was c omplete o n the return o f the catamenia after thfor several months .Ferguson Lancet, ’ 1872 , 11, 78) rec ords a case o f hysteria in a youn

girl, from whom 1 0 1 pins and needles were remo ved from the arm s anlegs .

Hodges ,“ Hysterical Clo sure Of Right Eyelids cured by Galvanism ,

” ‘Lancet,’1871 , i , 3 78. Bazin , Ob servation d

’Aphasie Hysterique (in a pregnant woman !

Gaz . des 187 1 , 446. Co rlieu,

“ Anesth és ie Muscul aire et Cutanée Oc casio nnp ar un Refro idissement, ou N évro se Cataleptifo rm e Hémiplegique,

” ‘L’

Unio n

o f Hysteria (girl, set. 19, auto psy), ih., ih . , 9 .

CEOREA. 81

Chorea .

Handfield Jones Med. Pres s and 1872 , i , 2 4) rec o rds fivecases o f cho rea ; in one girl act . 7 years , and two , set . I 3 , in each o fwhom the affec tion lasted six weeks in a girl o f 18, in whom its dura

was doubtful, and in whom there was a curious m ingling o f m o to rm enta l dis o rders ; and in one b oy act. 1 0 years

,in whom its dura

was abo ut eleven weeks . These cases illustrate the fo llowingis order

the em o tional o r o f the intellectual centres (2 ) in a m odified form

, and to be

complicated with qu (3) the absence o f rheumatismo r definite endo card (4) the varying duration and

causatio n o f cho rea ; 5) the certainty that the same remedy is no t

suitable to al l cases (6) the increased excretio n o f urinary so lids whichno t unfrequently o c curs in cho rea .

Butlin c ommuni cates to the Lancet’ ( 187 1 , I1, 5 76, 606) twelve

cases o f cho rea in children between the ages o f 7 and 10 years,treated

with sulphate o f zinc .

Gray and Tuckwell (ib .,11, 778) give a series o f eighteen ca ses

,six

under the o bservation o f the fo rmer, and twelve under th at o f the latter.

In none of these was any spec ial treatment ado pted from the first onsetto the c om plete disappearance o f the symptom s, calculated to influencethe nervous s stem . G o o d diet, the better hygienic c o nditions of the

infirmary , an pepperm int water were the only means employed. T he

cases Show well how remarkably cho rea is liable to vary in its duratio n .

is ten

threetained

cases ,random ,

and treated with arsenic,s teel

,&c . , to be ten weeks

days . T he mean duration o f eight cases treated in suc cess ionwell with arsenic in gradually increas ing do ses , after Begbie’ sS ten weeks and six days ; the longest case lasting sixteen, theseven weeks . Hillier puts the mean duratio n o f thirty c ases

See gives sixty-nine days as the average dura

cd. J 1872 , i , 342 ) showed to the Clin ical2 5 , with atrophy o f the right S ide o f her face,

horea rap idly Cured b y Arsenic, ” ‘Brit. Med.

gitatio n, treatedChorea aris ing from a b low ,

”ib . ,

5 2 5 . Sawyer, Cho rea fo llo w ing Acute Rheum atism ,

”ih .

, ib ., 5 2 7 . Ogle ,Cases o f Ch orea (two girls , set. 14 and 19, and a b oy, set. Lancet,’ 187 1 ,Dickinson , On Chorea ,” ih . , i , 504 . Hugh lings Jackson, Remarks on a

Cho rea in a Dog ,

” ih ., 1872 , i , 148. Radc l ifi e,“ Case o f Clo nic Spasms

,

g only when the patient (girl, act. 2 1) attempts to stand,”ih . , ih .

82 RE PORT ON PRACTICAL ME DICINE .

Ep ilep sy .

Brown -Sequard Arch . de 1872 , iv, 2 04) has arrested tlfits o f epilepsy which have been pro voked in guinea -

pigs , by sectio na po rtio n o f the Spinal c o rd, o r o f the s c iatic nerve

,by irritatiI

the thro at o r larynx by carbonic ac id gas . The s trength o f tl

gas must be such as to be alm o st in suppo rtable by the experimenteand mus t be injec ted with a certain am o unt o f fo rce . Injectio n o f tl

gas Simply into the no se o f the animal is insuflic ient,tho ugh the ca

m ay be different in the human subjec t. The autho r has als o VCI‘Ifi l

the experiments o f Ro senthal,that pulm o nary insufllatio n arrests ti

epileptic attacks provo ked by strychnine . At the s ame time he lo o fupon the explanation given as ab so lutely fals e, and thinks the arrestbe due no t to supero xygenatio n o f the blo o d

,but to the mechanic

irritation o f the air upon the branches Of the vagus distributed to tlbronchi , and to the nerves o f the diaphragm . The same results fOllOWlthe same experiments m ade on pigeons and a duck .

T he same writer Gaz . 187 2 , 466) c ommun icates to tl

So c iété de Bio logie the experiments he has made to determ ine the pafo llowed by irritatio n ,

which has been set up by sec tion o f the s ciat

nerve,in o rder to reach the upper part Of the s pinal c o rd, and pro dui

attacks o f epilepsy . Sec tio n o f the nerve, high up , and espec ialrem o val o f the nerve, c o nstantly pro duce epilepsy . But section o f tl

c o rd immediately abo ve the o rigin o f the nerve do es no t do s o . Th

unexpec ted fac t makes him think eptic symptom s are ui

due to section o f fibres o f the s c iathe sympathetic c o ntained in the s

to divide the filaments o f thetask was difficult, and the res

o f the last do rs al and first lumbar ro o ts,

filaments to the s c iatic,did pro duce ep ile

that artific ially produced epilepsy is pro bsympathetic nerve .

Westphal Berl . Klin . 187 1 , 448) hasthe experiments made by Brown -Sequard on gui

to the artific ial pro duc tio n o f

Ano ther interesting and new fac ta blow on the head may s et

c ondition as direct injury toImmediately o r s o on after th

84! RE PORT ON PRACTICAL MEDICINE .

Injury of the Head, fo llowed by Delirium , E pileptiform Convuls io ns , and Aphas ia(man, mt. Brit. Med. J 1872 , 11, 97.

Hemip legia and Ap has ia .

Perroud (‘Lyon viii

, 65) attempts to verify by s tatisBrown -Sequard’ s assertio n that the left hem isphere Is the centre o f

tellectual and anima l life, the right that o f o rgan ic life . T h

o f hemiplegic patients Observed by him self being to o small fopo se, he pres ses into service a n o te o f Charc o t , pubde Phys io lo gie ,’ in 1868

,c o ntaining the h l sto ry

p legia , in which death o c curred in the c ourse Of

sudden attack . They were all c omplicated with bthe paralysed s ide

,and this “ lesio n o f nutrition ’

lesion o f the right hem isphere (s o res o n the leftles ion of the left (so res o n the right s ide) . Perroud gives an

o f 70 cases o f chronic hem iplegia o bserved by him self duringfour years, in 3 2 right-Sided, 38 left- s ided . Of the fo rm er

,2 4

trouble o f nutrition ,8,i. efo ne fo urth o f the c ases , had . O f th

2 6 had none ,and 1 2

,i. e . one third o f the cases

,had.

Fieber Klin ische Studien iiber die Brown -Séquard’

s che

lahmung,” W ien Med. Zeitg ,

’

187 1 , 166, &c . ) rec o rds fo ur

Spinal hemiplegia, with muscular para lysis o n o ne

on the Oppo site s ide . He think s these ca ses are mo re

generally suppo sed, and as o verlo oked when,as is o ft

sation returns , while the paresis remains . He gives (iharrangement o f the fo ur cases .Verneuil gives Bull . de l ’Acad. de Jan . 187

the case o f a man , set. 46, in whom , after h

only numero us co ntusions c o uld be fo und, bo f vio lent delirium , right hem iplegia , and

died fifteen days later,and the auto psy showed c om

two internal c o ats o f the left caro tid,with a c lo t in

into the branches o f the Sylvian artery. There waso f alm o st the who le m iddle lo be .

Bro adbent Med -Chir. lv,145) has pub

paper on the cerebral mechan ism Of speech an

has been , by means o f the light thrown upcases o f lo s s o r derangement o f Speech , tosubject stated, and to c onnec t this with thes o far as they are at present known . T he pthe auto ps ies o f whic h are given as fully asc ases, SO far as they bear on the question

,are entirely

the view which assIgnS a c lo se func tional relatio n withto that part o f the upper edge o f the fis sure o f Sylviuspo sterio r end o f the third frontal c o nvo lutio n o f theThe writer critic ises cases which may seem to bear o n

HEMIPLE GIA AND APHASIA. 85

n ode . In the cases distinguished by Bastian , Hughlings Jacks on ,W .

Ogle, Sanders , &c .

,as amnes ic o r amnem onic

,and ataxic o r aphas ic ,

the les ion has o c curred at different po ints . Bro adbent quo tes hiseighth case in illus tration . Here

,while the o bjec t seen n o longer

evo ked the appro priate name,the name and the o bject presented to

0 o ne ano ther ; the channel(the intellectual c entre) wasin severance of the audito ry

the patient, and he will have n o idea whether he issaying what he wishes o r no t . Bo th as to m ental c ondition and seat o fles ion these ca ses would be different from amnes ic and aphas ic cases .The autho r states at s ome length the result o f his own o bservations onthe c o urse and distribution o f the fibres in the c erebral hem ispheres .

He enumerates the c onvo lution s which have n o direc t c ommun icatio nwith the crus , central ganglia, or c o rpus c allo sum ,

the said c onvo lution sbeing latest in o rder o f development

,and c on stituting the difference

between the human and quadrumano us brain,withdrawn , s o to speak,

from the o uter wo rld,

and “receiving the raw material o f tho ught

from the c o nvo lutions on which sens o ry impres s ions impinge, and em

ploying fo r the transm is s ion o utwards o f the vo litional product tho sec o nvo lution s which are in c ommunication with the m o to r ganglia and

trac t . ” He ado pts , with m o dific ation,the theo ry o f Bastian On the

Mus cular Sen se and on the Phys io lo gy o f Thinking, ” ‘Brit . Med. J1869 ,

May) , giving it an impo rtant extension, and applying it to the

fac ts o f cerebral s truc ture . After c ons idering the two distinct aspectsin which wo rds m ay be c on s idered—1

,as m o to r pro ces ses, 2

,as intel

lec tual symbo ls—and expres s ly stating that reading and writing havebeen kept o ut o f s ight fo r the sake o f c learnes s , and the mec hanism o f

tho ught as s uffic iently exp lained In the c o nsideration o f that o f speech ,he gives the fo llowing as a résumé o f his theo ry( 1 ) Wo rds

,as remembered s ounds , will be represented by cell-gro ups

summit o f the receptive Side o f the nervo us System , which , fo rS given ,

is suppo sed to be situated in the marginal c onvo lutionshem ispheres .From these cell groups , when definitely fo rmed, impressions will

a in the superadded c o nvo lutio ns , to whichto the m ind the various pro perties o f o b

ed a ll these impress io nshe symbo l fo r the resu lt

ing idea o f the o bject .3) Almo st s imultaneo usly m o to r c ells in the c o rpus striatum are

gro uped for the pro duc tio n o f articulate wo rds , under the guidance o fthe

remembered s o und, in respon se to efl'

o rts at im itation, which are at firstmo re o r les s parro t-like . T he cell-gro ups fo r Spo ken words o nce fo rmedare

,however

,employed almo st exc lus ively In intellectual expres sion .

(4) The rec eptive cell-gro ups fo r remembered so unds will be foundin the marginal c onvo lutio ns o f the two hem ispheres , which are symme

trically a s so c iated by the c orpus callo sum ,and the cell-gro ups fo r spoken

so unds will b e found In the two c orpo ra striata ; but the absence Of


c omm is sural c onnec tion between the superadded c o nvo lutions o f thetwo hem ispheres permits o f the predom inant , if no t exc lus ive, education o f the left hem isphere fo r the verbal expres s ion o f the produc t o f

intellectual ac tion,as has been revealed by patho logy. This is an

efferent pro cess , and do es n o t imply the exc lus ive use Of the hem ispherein tho ught .5) The o utlet fo r intellectual express io n in Spo ken wo rds , which are

mo to r ac ts,is nec es sarily in some part o f t e margina l c onvo lutions in

relatio n by fibres with the c o rpus s triatumthe po int to be the left third frontal gyru s .

(6) T he left third gyrus being the o n

c o rpus striatum neces sarily takes the leadwo rds , but a way round exists , probablythird frontal gyrus by the c o rpus ca llo sum .

po rarily embarrassed by damagevered ; wherea s , if the c o rtex o f

damaged, o r ithro ugh , Speech , having no o ther o utlet, is lo st .Bristowe (‘Brit . Med . J 187 1 , i , 1 2 2 ) read a

illus trative o f the various fo rms o f impairmen t o r lo s sspeech . Co nsidering aphas Ia under three heads , heexamples o f that fo rm which is due to a m ental defec t, independeany affection o f the o rgans o f speech (amnesia , amnestic aphas ia) .these four cases had hem iplegia . o f the right side . Tho ugh inc ases the lesio n was on the left s ide o f the cerebrum ,

Trous seau ,that aphas ia in s ome instanc es is Obvi

disease o f the right hem isphere, and ho lds thataphasia o n disease o f

left Side , is at present very far from certain . As an illustrationsec ond fo rm o f aphasia

,in which the patient , witho ut any mental

o r paralysis o f the o rgans o f Speech , lo ses the power o f

a bso lutely, he gave a cas e in whic h he had succeeded in

ing a pers on to Speak (cf. ‘Trans . C lin . iii,

He

that cases o f this kind lead to the c o nc lus ion that speecho nce acquired, is a purely reflex phenomeno n,

o f deglutition and respiratio n ; that there is s om

intermediate between the cerebrum (which thinks and

nuc lei o f the m o to r nerve o f the fifth,the po rtio dura ,

glo s sal nerves , and that aphasia is due in these c ases to

c o -o rdinating centre . T he third fo rm was il lustrated bythe nerves o f speech were paralysed, either from diseasesome o f the trunks

,o r their nuc lei o f o rigin .

Sam t ( “ Zur Aphasiefrage ;” ‘Arch . f. Psych

,

’ iii, 75 1)

po st-m o rtem appearances fo und in the brains o f two aphasic s .

eludes with the assertion that it is impo s s ible at present to locentre o f speech , and idle to discuss the po s sibilHammo nd New Y o rk Med . vi

, 1 )c ondition pro duced by an afl

'

ec tion o f the brailanguage, o r o f its expres s ion ,

is impaired.

”

HEMIPLE GIA AND APHASIA . 87

Crichton described it, to the latest perio d. He rejects the theories o f

Bax and Bro ca , and believes that the o rgan o f language is S ituated inb o th hemispheres , and in that part which is n ourished by the m iddlecerebral artery ; and that while the m ore frequent o c currence o f righthemiplegia , in connectio n with aphasia, is in great part the result o f theanatom ic al arrangement o f the arteries , which favours embo lism on thatside, there i s strong evidence to Show that the left s ide o f the brain ism ore intimately c o nnected with the faculty o f Speech than the right . ”Histo ries o f fourteen cases o f aphasia , which had c ome under his o b servation

,fo llow ; and from these he c onc ludes that in al l o f which

hem iplegia fo rmed a feature, the aphasia was o f the ataxic fo rm ,while

when there w as n o hem iplegia , the aphasia was amnes ic . In the one

the individual was deprived o f speech , because he c ould no t c o - o rdinatethe musc les used in articulation in the o ther

,because he had lo st the

mem o ry o f wo rds . He thinks that this po int has no t been no ted befo re ,and that the phenomena indicate very c learly the seat o f the lesion and

the physio lo gy o f the parts invo lved. When the grey matter o f the

lo b es,which presides o ver the idea o f language and hence o ver the

mem ory o f wo rds,is alone invo lved, there is n o hemiplegia, and no difli

culty o f articulation . If the c o rpus striatum ,o r s ome o ther part o f the

m o tor tract is attacked,the les ion is fo llowed by hem iplegia and ataxic

aphasia ; and if amnesic aphasia is also present , the hem isphere is likewise invo lved.

Bristowe Path . S o c . xxiii,2 1) records the case o f a woman

,

act. 48, in whom the left c o rpus striatum with the brain substan cebetween it and the island Of Reil was entirely destroyed by a c lo t . Dur

ing life She had c omplete m o to r hem iplegia, temporary aphem ia , andslight amnes ia .

Baginsky Berl . Klin . Wo ch .,

187 1 , 42 8) rec o rds two cases o faphasia , in men aet . respec tively 4 2 and 40 , in c onsequence o f diseasethe kidneys , and dis c us ses at s ome length the relation o f the two

seases , and espec ially the anatom ical seats o f the aphas ic les ion .

Simon Casuistis che Beitrage zur Lehre vo n der Aphasie,’ ib . ,

a very interesting paper with ca ses o f the affec tion . He

the les io n is to be fo und in the third fron tal c onvo lution ,

always o n the left s ide,and thinks that the faculty o f speech

Sides in bo th , tho ugh we are in the habit o f using on ly the

ast case is that o f a m an who was thrown with his horse,and

,attempting to get into his saddle again ,

was found to have c ompleteaphas ia , and a small wound in the head. Death fo llowed later frommeningl tis , and a splinter o f bo ne was found impinging on the thirdleft c onvo lutio n

,with s o ften ing o f this end o f the th ird c onvo lutio n ,

and

the island o f Reil .Hughlings Jacks on (‘Lancet 1872 , i , 72 ) gives a m inute repo rt o f

the case Of a healthy girl, act . 1 7 , in whom a right-s ided c onvuls ion wasfo llowed by defec t o f speech , from wh ich she rec o vered. T he c onvul

sions did n o t resemble tho se which o c cur in hysterical women,and was

like tho se o ccurring in brain disease ; and he infers that there musthave been some patho logical pro cess , as yet unknown ,

in the region o f

the c o rpus striatum .


The same autho r (ib . ,187 1 , 11, 430) repo rts two c ases Of the pow

singing existing in two aphas ic boys o f the ages o f ten and eight yBac o n (ib .

, 488) rep o rts the c ase Of an idio t bo y, ast. 1 2 , with st

family histo ry o f physical degeneration ,who , s carcely able

S ingle wo rd, has a c ertain capac ity o f humm ing tunes .

Down (ib .

,187 1 , i , 85 2 ) rec o rds the case o f a man mt. 2 8,

right- sided hemiplegia , with unaffec ted speech , and an ao rtictive murmur. A week later he became speechles s, and two (1

wards died . The auto psy showed, in addition to the ao rtics o ftened cavity o f irregular Shape, and o f abo ut the s ize o f a

in the anterio r lo be o f the left Side o f the brain .

N ico l, “ Shfting and Recurring partial Hem iplegia in a Patient su

Bright’s Disease ”

(m an , set. Lancet, ’ 187 1 , i i , 397. Ogle, Caseand Hem iplegia, pro bab ly syph ilitic ”

(woman, act. 3 ih ., 540 .

prob ab ly from s oftening o f Embo l ic Origin ”

(woman, wt. ih .

p legia , ih . , ih ., 6 10. Lo ckhart Clarke, Inc omplete Hem iplegia of the

w ith partial Aphas ia , ” ih ., ih. ,638. Ogle, On Dextra l Preem inenc e, ”

liv, 2 79 . Wrany, Hem iplegie und Ap has ie m it Hem icho rea inE ndoc arditis , ” Oesterr, Jahrb . f. Paadiatrik,

’187 2 , i , 1 2 (see under Dis .

tio n). Greenh ow ,

“ Plugging o f the Left Anterior and Righ t MiddlArteries , E xtens ive Disease o f the Fro nta l L obe o f the Left Hem is

o f the Righ t S ide, lo ss o f po wer of speech, death , auto p syfrontal lo be, c orresponding to the interio r and po s terio r part o f the fro ntaltio ns, and very c lo sely bo rdering o n the c entral lo be, dis eased b loo d-vessels),1872 , 11, 706 .

Hyp erccsthes ia and Neura lg ia .

An stie,“ Neuralgia and the diseases that resemb le it, ” London, 187 1 .

On Neuritis o f the Brach ial Plexus, ” ‘Med.-Ch ir . l iv

, 145 . COb servatio ns on Dr. C . B . Radc liffe’s Theo ry o f the Genesis Of Pain,

and 187 1, ii, 765 . Ans tie,“ On the Pa tho logi ca l and

o f Asthm a, Angina Pec to ris , and Ga stralgia, ” ‘Bri t. Med .

Id., A Case o f Neuralgia o f a ll Three Branches Of the FiHandfield Jones, Clinical Lec ture o n Hyperaes thes ia,“ Som e No tes on Neuralgia and its Treatment, ” ih . ,

i, 639 .

Neura lgia,”ih .

, 1872 , i, 139 . W i lks , On S ick Headache,

NEURALGIA .—MENINGITIS

,ETC . 9

“ Contributions to the Clin ic al Histo ry Of Hyp'

eraesthes ia, ” ‘Amer. Journ . Med.

lxi, 10 5 . Cleb orne, Headache,” ‘New Y o rk Med . vi, 309 . Meiere, “ Treat

m ent o f S c iatic a, ” ih ., 1 75 . No thnagel, Schm erz und cutane Sensib ilitats -St '

drungen,

Ve ll . l iv. , 1 2 1 . Peter, Névralgie Diaph ragmatique et fa its Mo rb ides Co nh exes,

” ‘Arch . Céu. dc Med .,xvii, 303 . So rb ets, Deux ca s de Névralgie Cervic o

bra ch iale No cturne, Gaz . des 187 1 , 566. Senne,“ De la Migra ine, ” Un io n

xi, 4 23 .

M eningitis Hydro cep ha lus He morrhage.

A writer in the G'raz . Méd.

’

(187 1 , 4 1 2 , o n the treatment and

pro phylaxis o f tubercular m eningitis , s ays that in a prac tice o f thirtyyears he has seen between eighty and ninety cases, and in that timec ounts two as rec o vering from the c onfirmed disease.

Flem ing Brit . Med. 187 1 , 443) thinks he had to deal witha case o f unequivo cal tubercular men ingitis in a girl act . rec o veryfrom which may have been due to the use o f iodide o f po tas s ium .

MacSwiney (ib .,1872 , 539) exhibited t

‘

a Spec imen showing tuberc leo ver the projec ting po rtions o f the cerebral c o nvo lutio ns

,taken from a

boy, act . 15 , who five weeks befo re had bec ome suddenly inc o herent .An epileptifo rm c o nvuls ion fo llowed in a few m inutes , and o c curred

again ten days later . There wa s dull, pers istent pa in in the head,general anaesthesia , a quick pulse, and sluggish , dilated pupils .

Sperling 187 1 , 448) has made injectio ns between the

dura m ater and the arachno id o ver the co nvexity o f the brain in rabbitswith the fo llowing rc sults :—E ight days after the injection o f fresh

blo od it began to be o rganized into a c o nnec tive-tis sue membranewhich was c o mplete after two to three weeks . After the latter perio dnew blo o d-ves sels were fo und in the new m embrane

,which agreed in all

charac ters with the m embrane o f'

pachymeningitis . The o rganizationo f the blo od o ccurred o ver the c onvexity o f the brain

,on the inner sur

face o f the dura m ater, witho ut any adhesio ns to the arachno id . T he

fo rmatio n o f the new membrane was due to the o rganizatio n o f the

fibrin co ntained in the blo o d . That this was SO was shown by the fac tno new formation was fo und after the injec tion o f defibrinated blo od

,

which was c ompletely reabso rbed. Injec tio n s o f io dine and o ther irritating fluids was n o t fo llowed by any new fo rmatio n . In some cases

the dura mater was found thi ckened,in o thers there was pus .

Arndt Vireh . lii, 42 ) reco rds two c a ses o f s o - called hydro

cephalus externus , due to the ac cumulatio n o f serum between the duramater and the arachno id. This ac cumulation wa s the result o f chronicinternal pachym eningitis , caus ing the fo rmation o f thick and to ughfalse m embranes , which bo und do wn the dura mater . This affec tio nis no t to be c onfo unded with Hygroma o f the dura m ater .

Thompson Brit . Med. J 187 1 , ii , 1 54) rec o rds the o c currenc eof intracranial o steophytes in a servant girl , act. 2 3 , w ith dilatation o f

the ventric les and increased fluid, am ounting to Seven o unces,and so ft

ening o f the white substance . N o tuberc les were p resent anywhere .

Bierb aum ,Patho logische Physio logic der Meningitis Tuberculo sa, ” ‘Deut.

187 1, 2 61 . Id Sem io tis ch -diagno stisch e Analyse der E rscheinungen b ei der Meningitis tuberculo sa, ” Journ . f . lvi . 32 4 . Neureutter, Fractura

Crann Sanata , Pachymeningitis interna chro nica , Hydro cephalus 11nd Tuberculo s is


b ei einem If Jahre alten Knaben ,

” ‘Oesterr. Jahrb . f. Paediatrik,’1872 , i, 1 2 3 .

Bro adbent,“ Cases o f Acute Cerebra l D iseas e, w ith Auto ps ies ( 1, Sew -

purulent

effus ion into ventric les o f b ra in, o b s cure symptom s 2 , Bas ic tubercular m eningitis),Med. Tim es and 187 1, ii, 3 76. Heller, E in Fall vo n Hydro c eph alus E xten

‘Deut . x, 2 0 7. Gant,“ Case o f Ap op lexy Treated by Venesection, ”

‘Lancet, 187 1, 11, 5 77 . Hughlings Jacks o n, “ Rem arks o n the Difficulties in the

Diagno s is o f the Causes o f Apo plexy, ” ih . , 1872 , i, 505 . Wh itc om b e, “ MeningemApoplexy ”

(m ale, se t .

‘Brit. Med . 1872 , i, 2 7 . Fo o t,“ Apop lexy, E x

trava sation o f Blo o d at th e Base o f the Bra in, Cylindro id Aneurism o f Fourth Stagso f Verteb ral Artery (m ale, act. ih . , ih . , 4 24 . Rittmann ,

“ Die V o rlanfer dcr

Apo plcxie und Synco pe,” W ien . Med. 187 1, 60 . Stille, S im ple Acute

Men ingitis ” (m an w ith chronic tub ercular phth isis , death from c oma and c o llapse,no tuberc les, o nly injec tion o f m en inges, w i th pus and lymph on pia m ater o f con»

vexity o f b rain), Am er. Journ . Med . lxi, 4 19 . Buttenw iesen , Punctio n und

Adsp iration eines Chro nischen Hydro cephalus m ittels t der Spritze von Bresgcn,

”

Deut. x, 30 1 . S chm id, Zur Difi ercntialdiagno se von Apo plexie und Embo liedes Gchirns,

”ih., 30 5 . Ko rber, “ Des Cheyne-Stokes ’sc he Resp iratio ns -Phanomerl

b ei einem an Meningitis Tub erculo sa leidenden 9 Mo natlichen Knabcn (no auto psy) ,ih 600 .

The Op htha lmo scop e in Diseases of the Nervous Sys tem .

Bo uchut Gaz . des 187 1 , 9 7) gives the fo llowing as seencases o f acute affectio n o f the brain and spinal c o rd.

Optic hyperaem ia and veno us stas es in the retina, c o inc iding wc onges tion o f the meninges o r thrombo s is o f the s inuses .

Optic neuritis , with o r witho ut exudation,the result o f men

'

enc ephalitis .

Pap illary oedema diagn o stic o f c erebral c ompres s io n .

Tubercles Of the cho ro id a lways ac c ompanied by tubercles o f

meninges o r the viscera .

He gives three cases with auto psies1 . G irl

,act . 2 tubercular meningitis and general tubercul o

during life alm o st entire disappearance o f the Optic pupilsented a unifo rm red c o lo uration m asking its o utline dil

retinal veins ; no cho ro idal tuberc le .

2 . G irl,act. 8 ; do uble o ptic neuritis and m iliary tuberc les

cho ro id general tuberculo s is .

3 . G irl,act . 3 atro phy o f b o th o ptic nerves , as seen with t

thalmOSCOpe ; a tuberc le (scro fulo us tumo ur,—Rep .) o f the cc re

the s ize o f a hen ’

s egg, and two the s ize o f nuts,a t the surface

right cerebra l hem isphere ; en o rmo us quantity o f fluid in the

ventric les ; no m iliary tuberc les anywhere .

So cin Beitrag zur Lehre von den Sehsto rungen beiMeninDeut . v111

, 476) rec o rds two c ases,in a man

, act . 3 1 ,female

, act . 3 7, in whom ,suffering with m eningeal symptom s

, ths o rt o f appearances in the Op tic dis c were Observed as in

tubercular m eningitis .

Bro adbent Path . So c . xxiii,2 16) rec o r

Of the sheath o f the o ptic nerve in m en ingiti s .

act. 19 , had c omplained o f headache fo r a fo rtnight.lay in a state

Slhggistachcs


between general and partial acute idio pathic cerebritis .

the diagno s is o f the disease no t diflicult . It differs fromfo rm o f softening, in the absence o f aphas ia and

—

para lyo ther general features o f progres s ; from the c onvuls ive fo rm ,

in

absence Of epileptifo rm attacks at the beginn ing, and the greaters tancy and duration o f the c o nvulsio ns when they do o ccur ; from

delirio us fo rm,by the m o de o f invas io n which is never by delirium

,

by the les s marked charac ter o f this sym ptom thro ughout .Fleischmann W ien . Med. 187 1 , No . 6

,&c . ) rec o rds a

o f cerebralin the leftinto the lefto f the inner surface . The symptom s

Afanasieff (ibid.

,1870 ,

N o . 9 ) in sec ti

were partial paralys 1s o f the left o culop up11, which was unaffec ted by light ;mus c les o f the trunk and extrem ities o f theright hand ; increased cutaneous sens ibilityexception o f the head ; Ophthalmia ; hyperaeand o ptic disc o f t he left eye ; in capac ity o fa bno rmal fluc tuatio ns in temperature .

Co rdier (‘Lyo n viii , 583) rec o rds the c ase o f

suffering from caries o f the ribs and empyema , in whom threeo f the left cerebellar lo be had been de s troyed by a tube(i. e. scro fulo us

,

” —Rep .) tum o ur, witho ut giving risesym ptom s . l

,

‘

Hughlings Jackson Brit .‘Med. 187 1 , i1, 5 2 8) puc ase o f tumour o f the m iddle lo be o f the cerebellum in a bT he tumo ur was a tuberc ulous ” o ne

,o f the s ize o f a bil li

T he diagno s is was gro unded o n ( I ) the enlargement o f the ho ut any evidence o f ric kets (2 ) blindnes s (do uble o ptic(3 ) a reeling gait . Perhaps o f the three the las t wast ho ugh by itself it wo uld o n ly po int to a tum o ur und

Fro m time to time the b oy had c o nvuls ive seizures o fduring which he was c o ns c io us .

Bro adbent (‘Brit . Med. 1872 , i , 4 76, 6 2Clinical So c iety the histo ry o f two cases

,in o ne o f

two tum o urs j ust beneath the flo o r o f themedian line—o ne in the lower half o f the

lower end o f the ventric le . T he patientsymptom s during life were slight weaknes spara lys is o f the left S ide o f the fac e

,n o t

latera l deviation o f b o th eyes to the ri

lo s s o f s ensatio n o ver the area o f thedeglutition and indistinc t articulatio n . In the sec o nd c ase

,a man

65 , gh omato us tumo urs were fo und in the o c c ipital lo be , and inpo sterIo r a s cending parietal c o nvo lution o f the rIght hemisphere .

had c o nvuls io n and para lys is o f the left half o f the body .

Hutchinson (ibid. , 185 ) writes o n a case o f suppo sed cerebral tumIn a man act. 2 7 , al1ve at the time o f writing.

TUMOURS OF BRAIN . 93

E vans (ibid.

,187 2 , i , 366) refers to the o c curren c e o f an hydatid cys t

pro truding from the under surface o f the cereb ellum in a b oy act . 1 7 ,

who in addition to rheumatic endo carditis had headache , dimnes s o f

vision , and a staggering gait.

Pullar ( ibid., 3 1 2 ) rec o rds a c ase o f the same kind in a girl set. 4 .

T he cyst, the S ize o f a p igeo n’ s egg, lay upon the crus cerebelli o f the

left s ide . She had perio dical headache, trem o rs o f the limbs , and laterwas in a s em i-unc o ns c ious state

,from which she was eas ily roused.

(And see this Repo rt, under Animal Paras ites”

)Janeway and Teakle New Y o rk Med. Rec o rd,

’ vi, 403) give a

des cription o f tumo urs attached to the dura mater.

E des Amer . Jo urn . o f Med. lxi, 87 ) g1ves three cases o fm orbid

growth c o nnec ted with the nervo us system,al l o c curring in women ,

who se ages respectively were 83 , 60 ,and 7 1 . In the firs t there was a

gliom ato us tum our o f the c erebrum in the sec ond a round-celled sar

c oma o f the c ereb ellum ; and in the third there was sarc oma Of the

semilunar ganglion o f the sympathetic , varying in character from a

c ellular to a fibrous structure .

Reynaud ,“ Ac c idents C érébraux Survenus Consécutivement a une Tum eur b lanche

Cervic ale, m o rt ct autop s ie (boy, act. Lyo n vi i i, 2 65 . Fagge, Emb o lism

of the Left M iddl e Cerebral Artery of m ore than six w eeks ’ s tanding, yellowinduration o f the c o rpus striatum , w ith surro unding wh ite softening ”

(wom an , set.

2 5 , right hem iplegia w ith a phas ia) , Path . So c . xxn , 13 . King, “ Aneurismof the Aorta a s so c iated w ith Fracture o f the First Rib , and Emb o lism o f MiddleCerebral Artery,” ih .

, xxiii, 70 . Ha slewo o d, “ A Case o f Disease o f Right Interna lE ar, and resulting Ab sces s in the Bra in ”

(m ale, ac t. Lan cet, ’ 1872 , i . Broadbent , Disease o f Tem po ra l Bone, ab s ces s in tem po ro -spheno idal lo be o f bra in Open inginto ventric le, pro longed suppuratio n in ventric les, ” Med . Times and 187 1, ii,3 77 . Draper

“ Abc es s o f Bra in, Aph as ia ,” ‘New Y o rk Med . G az July, 187 1, 76.

Blanquique,‘Tumeur dc la G lande Pinéale, épanchement abo ndan t , hernies du cer

veau a travers la dure mere, ” ‘Gaz . vi ii, 5 3 2 . Bro adb ent “ T um o ur in LeftHalf o f Flo o r o f Fourth Ventric le , w ith Tum our in Cerebellum (gliom atous , girl,act . Brit. Med. 187 1 , 11, 7 10 . W ilkinson, Malignant Disease (gliom a )o f the E ye, Brain, and Cranium ”

(b oy, ac t.‘ Tran s . Path . xxi ii, 2 2 0 .

Arno tt, S crofulous Tum ours in Brain and Testic le, from a c ase in wh ich the elbowj o in t had b een exc ised two years previously, ” ih . , 5 . Hawkes, “ Ca se o f Tum our o f

the Bra in , apparently o f the Nature o f E ncephalo id Cancer, ib ., 3 2 . Sto cks ,“ Tum our o f Brain (m edullary, m an, act.

‘Brit. Med. Jo urn 1872 , i, 13 7.

Th om as,“ Cereb ra l Tum our (degenerated dermo id cyst P), ib .,

ib ., 45 7. Lyda l]A Cas e o f Bony Tum our in the Sub stance o f the Bra in ”

(wom an, act. Lancet,187 2 , 11, 5 24 . Manning, Two Cases Of Medullary Canc er o f' the Bra in (m en, act.

60 and 50, w ith auto p s ies), ih ., 187 1, 11, 3 2 1 . Deane, Case o f Ossific Depo s it underthe Dura Mater (man , act. 2 2 , autop sy), ib ., 1872 , i, 147 .

Sp ina l Afi ec tions .

Hallo peau (“ E tude sur les Myelitis Chron iques difl'

uses,

” ‘Arch .

G én . dc xviii,2 77, &c .

, xix, 60 , gives the fo llowing c las s ification o f the different fo rm s o f c hro n ic myelitis . It is s carcelypo ss ible to abstract the artic le with justice.

94 RE PORT ON PRACTICAL M EDICINE .

Of the grey sub Pro gres s ive musc ular atrophy .

stanc e . Infantile paralys is .

Prim itive (progres s ive loc om otorataxy) .

Po sterio r. Secondary (as c ending degenera

tion in cases o f c o mpress ion of

Of the wh ite sub th e co rd, partIa l myeh tis,

stance.

Prim itive (Charc ot’ s cases) .econdary (des cending degeneraAnterio r. tio n in cas es in wh ic h the m o torfibres are injured, ei ther in theirSp inal o r c erebra l portio ns) .

In dis sem inated ]patches .

Genera l. ITh ese m ay invo lve the cord thro ugh out its

Diffused. 4 Periphera l (mye length , o r o cc upy a po rtion only m o re o r

lo -m en ingitis) . less extens ive.

Round the epen lL dym a (ccntral) . J

With Vulpian he c onsiders the first stage to be irritation and infl

mation o f the nerve-elements , e . g . the nerve-tubes in tabes dthe spinal ganglio n-c ells in mus cular atro phy . T

tum ours,severe fevers , the

tebras , inflammatio n o f the

Difiuse myelitis is c onstantlhas been o bserved in cho reaat its first c ommencem ent,

spaces , generallyfluid. The interstitial myelitis is es sentially characl iferation o f the cells and nuc lei o f the neuroglia .

in c entral myelitis is ac c ompanied by pro liferatio n o

ments o f the central canal . The ro o ts o f the nerves,

tis sue with atrophy o fthe nerve-fibres) . In caseswhcr

is affec ted the m us cles are atro hied. These changesnec tion with diffuse myelitis have fo r twenty yearsDuchenne as general spinal paralys is .

”

G enerallysuddenly with pains in the do rsal regio n ,

from which


liv, 4 2 . Westphal, Ueber ein E igenthumliches Verhalten Secundarer Degenerationdc s Ruckenm arks (with p late), Arc h . f . ii, 374 . Sc hule, Weito rer Beitragzur Hirn-Ruckenm ark s -S c lero se, ” Deut. viii, 2 2 3 . Kelp, Hirnsklerose, ” ih .,

x, 2 24 . Buc hwald, Ueber Multiple Sklero se des Hirns und Ruckenm arks ,”

ih ., 4 78.

Otto , Casuistischer Beitrag z uMultip len Sklero se des Hirns und Riickcnmark s ,”ih .,

53 1 . E b stein, Sc lero s is Medullae Sp inalis et o b longata: a ls Sectio nsb ef’

und bei cinen

F.1l le vo n Sprach und Co o rdinatio nssto rung in Armen und Beinen in Fo lge von

Typhus Ab dom inalis, ” ih., 595 .

Infantile P ara lysis .

Dam aschino andRoger Gaz . 187 1 , 457) c ommence their longpaper by trac ing the histo ry o f the affec tion and the suggestions madeby differen t autho rs as to its cause . Heine ( 1840) andDuchenne (185 5 )referred its o rigin to the S pinal c o rd, though they had no pa tho logica leviden ce o f disease in the latter. Bo uchut plac ed the anatomical s eato f the lesion in the mus c les , and the disease among the muscularparalyses (myogéniquc s) . Co rn il in 1863 , and with Labo rde in the fo llowing year, gave the result o f their anatom ical investigations , and thelater writer rec o rded a sec o nd cas e also their example was fo llowed byPrevo st and Vulpian in 1865 , O livier in 1869, Charc o t and Jo ffroy In

1870 , and in this last year also Parro t and Jo ffroy. Damasch ino and

Ro ger them selves had Oppo rtunities o f a full exam ination o f three cas esin 1868

,1869, and 187 1 , o f which they now give full repo rts . T he

first c a se was that o f a b oy aged two years , who fo r two m o nths hadsuffered with paralys is o f the left arm with atrophy o f the delto id—a

c onsequence o f hem iplegia o c curring after dys entery . Parap legiaset in during meas les

,o f which la st affec tio n the child died. T he

s ec ond case was Observed in a b oy ac t. 2 3 years , who fo r six monthshad had paraplegia, with atro phy and defo rm ity o f the left leg, les smarked in the right. He also died o f meas les . T he third case was thato f a b oy o f 3 years , who had paraplegia and paralysis o f the musc les o f

the left bac k fo r thirteen m o nths befo re he died o f broncho -pneumo nia .

T he symptom s during life and the patho logical appearances were s im ilarin all three cases . T he changes in the musc les were o f the o rdinaryc harac ter, c onsis ting o f fatty and fibro id degeneratio n o f the fibrillae.

In the spinal c o rd the writers found the same les ions o f the grey sub

stance and the anterio r and lateral c o lumns,differing, in the three cases ,

o nly in its seat ; in the firs t case,in two places , the c ervica l and lumbar

enlargements ; in the seco nd,chiefly in the latter po s ition ; and in

the third c ase,in the same regio n , but o n bo th s ides . T he mic

ro sc o pe revealed changes in the ves sels, thickened walls , pro liferation o f their nuc lei, atro phy o f the ganglio n -cells and their pro

c es ses,as well as o f the nerve-fibres . There was als o thickening o f the

c onnective tis sue (s c lero s is) , espec ially marked in the third case . Thesefacts lead the autho rs (ih .

, 5 78) to the c o nc lus ions that the les ion o f the

s pinal c o rd is es sential and primary, and that the pa tho lo gical appearances found justify their use o f the term spinal infantile paralysis ”paralysie Sp inale dc The lesion they c onsider to be a

myelitis , espec ially o f the anterio r grey substance, o f which the atro phyo f the nerves and musc les is the c onsequence .

PARALY SIS AGITANS . 97

Rineckcr Berl . Klin . 187 1 , 62 7) gives the auto ps ies o f twocases , which differ but little from the preceding . In the sec o nd o f the

two the anterio r and lateral c o lumns , as well as the nerve fibres and

ganglia , were atrophied, and in bo th the peripheral nerves .

Ro senthal 1872 , 1 76, quo ted from Oestr. Zeitschr. f.

prakt . Heilkunde,

’

187 1 , N o . 5 2 ) c ontributes a paper towards the c linicalandanatom ical knowledge o f sp inal infantile paralys is . Frenchwriters (cf.

1870 , 540) had espec ially called attention to the atro phy

chenne, Ro senthal finds that the m o to r p ower o f paralysedro ves without any return o f exc itability by faradisation o r

If within the first Six o r nine months from the c ommence

affection the electrical exc itability be c ompletely lo st, theno t fo r that reas on unfavo urab lefi“

Hitzig u . Jurgensen,“ Zur Therap ie der Kinderlahmung, ” Deut. ix, 330 .

Barwcll, Infantile Paralys is and its resulting Defo rm ities , ” Lancet, ’ 1872 , i, 2 49&c . Vulp ian,

“ Anatom ic Path o lo gique de la Paralys ie Infantile, ” ‘Gaz . Mcd .,

1872 , 9 . Ball , “ De la Paralys ie Infantile,” ‘Ga z . des 1872 , 185 . S im o n,“ E ine beso ndere Form der Kinderlahmung durch encephalo -malacische Heerde,

”

Vireh . lii, 103 .

P ara lysis Agitans .

Murchison and Cayley Path . So c . xxn,2 4) give the details

of a case o f paralys is agitan s , the sp ina l c ord o f which the latterexam ined, after hardening in chrom ic ac id

,and staining with carm ine .

1 . The c ortical o r c o nnective tis sue layer o f the c o rd appeared thickened, and presented an increased number o f nuc lei . 2 . Irregular tractsand patches o f c onnective tissue, thickly nuc leated, passed from the

co rtical layer into the substance o f the c o rd, the reticulum o f which wasmuch thickened. These patches were m o st frequently met with nearthe exit o f the po sterior ro o ts o f the nerves

,which themselves did no t

appear altered. 3 . The p lace o f the central canal was an o val trac t,

crowded with cells o f various shapes and s izes,the maj o rity having the

character o f leuco cytes,none presenting the character o f the n o rmal

epithelium o f the c anal . This o val tract o c cupied n o t only the site o f

the canal itself,but als o that o f the surrounding c entral sub stantia

gelatino sa . 4 . The c ap illaries o f the grey m atter, and to a les s exten tthe white, were distended with blo o d ; and here and there were smallpo ints o f extravasation . 5 . Thro ugh the who le c o rd, chiefly in the greymatter

,were small depo s its c ompo sed o f leuc o cytes o r exudation cells .

The first three changes were due to a chronic,the last two to an acute

,

o f the m orbid changes in these cases Gaz . deS

paper Bernhardt rem arks , Damasch ino also Ob served in twotile paralys is marked changes in the vessels o f the anterio rDuchenne seem in c lined to lo ok upon these changes as the

98 REPORT ON PRACTICAL ME DICINE .

187 1 , 60 2 ) is very similar. In all there was pro liferation o f the

epithelium c ompletely fil ling up the central canal ; grea t pro liferatio n of

nuc lei in the neighbourho od o f the ependyma pigmentatio n o f the

nerve cells, espec ially tho se o f Clarke’ s c o lumna ves iculo sa ; and a largequantity o f amylo id c orpus c les . In the th ird case there was a sc lero ticpatch o f c onnec tive tissue in the neighbourho o d o f the p ens withdilated vessels . The c onc lusion to which the writer c omes is that theseat o f the les ion in paralysis agitans is to be lo oked fo r in the cord.

All three cases o ccurred in women .

Chvo stek, E nc ephal itis der Geb ilde des r. Ammonsh o rns mit dem Ausgang inSc lero se, Paralys is ag itans der links seitiger E xtrem itaten (m an, wt. W ien. Med.

1871 , No . 3 7 . Bastian, “ A Case of Paralysis Agitans (man, act.‘Brit.

Med . J ii, 698.

Lo como tor Ataxy .

Greenhow and Cayley Path . So c . xxII, 14) reco rd a case Of

lo c om o to r ataxy in a m an act. 5 7, with a m icro sc o pical exam ination o f

the c o rd,Showing atro phy o f the po sterio r c o lumns .

Po llard, Loc om o to r Ataxy, c omm enc ing suddenly, and disappearm g under trea t

ment, w ith remarks ” (man, act . Lancet, ’ 187 2 , i, 43 1 . A lthaus , On the Pain

o f Ataxy and its Relief, ” ‘Brit. Med. J 187 1, i, 50 2 . Spillmann,

“ Tra itementdc l

’Ataxie Locomo trice, ” Gaz . viii, 369 .

Tetanus .

Cliffo rd-Allbutt publishes Path . So c . xxn,2 7) sho rt no tes

o f four c ases o f tetanus,with an exam ination o f the spina l c o rd in all .

Lo ckhart Clarke and Dickin son rep o rt on the same spec imen ,and the

patho lo gical results are

having, o n tran sverse sec tion ,c ircul ar o r o va l outlines

,

from disintegration o f the nerve-fibres . Cliflo rd-AHbutt strongly urgneuro tomy as a remedial pro ces s in tetanus .

Joffroy gives the m icro sc opical examinationthe c o rd, pons , nerves and mus cles , from a case o f traumatic tetanus .Tetanus has been treated with injections o f chlo ral hydrate

m o rphia by Aron Gaz . vn,No . by Dem arquay wi

injec tions o f m o rphia so lution Bull . Gen . dc t

Gaz . des 187 1 , by Nankivell Med. Times187 1 , i , M les Brit . Med. Journ .

’

187 1 , i , Tyrrell1 87 1 , i , Lawrence (ih . , Cro ft (ih . , 11, 636) and o t

ch lo ral hydrate ; by Fo ster (ib .,i, 5 72 ) with this drug and

amyl ; and by Fergus son (‘E dih xviii, 3 7) with

brom ide Of po tas s ium .

Kussm aul, “ Ueb er rheum atischen Tetanus und rheum atische ton iswelche m it Album inurie verlaufen ,

” ‘Berl . Klin . 187 1, 458 .

c ine Abortive Form des Tetanus , ” Deut . xi,m it Glyko surie, ” ib ., x, 103 . Koen ig, Das Ges ich


largely, o f partic les o f lead. He thinks that the m ixture o f the sun

c ontaining c erta in o f its so luble salts acts s lowly o n the lead case iwhich the snuff is packed. T he patient had lived fo r many years iCalcutta, where o ther cases o f the same kind had been o b served.

O ther papers o n nervous dis eases areLayco ck, Onthe Influenc e o f the Nervous System o n Diseases of the Organs arTissues, ” Med . Times and 187 1 , i, 3 1 , &c . Durrant , On Vertigo as a Sym

'

tom ,

” Brit. Med . J 187 1 , i, 88. Guéneau de Mussy,

“ Etudes sur la Sens ib ili'Réflexe,

” ‘Gaz . 187 1, 344. Mantegazza ,‘Dell

’

azione del do lo re sul la Dgestio ne e sulla Nutrizione, ” Gaz . Med . Lomb ., 187 1 , 4 5 . Hamm o nd,Treatise on Diseases o f the Nervous System,

”zud ed it. , New Y ork, 187 2 . E ulei

burg,“ Lehrbuch der Functio nellen Nervenkrankh eiten auf Phys io logischer Bas isBerlin , 187 1 . Handfield Jo nes , “ Cases of Neuro tic Disorder w ith unduly largUrinary Secretion ,

” Med . Times and 187 1 , i , 13 . Ogle, Two Cases illustratirthe Diagno sis between ap parent and real Intra cranial Diseas e, ” Lancet, ’ 187 1 , i , 85Moxo n,

“ A Case o f Intracranial Disease c ured by Io dide of Po tas s ium ,

”ih . , l l , 85

Fieber, “ Ueber eine no ch n ich t beschriebene Fo rm von Anom alie der Bewegungsbschriinkung ,

” ‘W ien . Med . 187 1, No . 4 1 . Anderso n, Rare Form of Spin

Irritation ,

” ‘Glasg . Med . Journ iii, 3 1 . Hutch ins , “ Sp ina l Irritatio n,

” ‘Ne

Y o rk Med . vi , 187 1, O c t. 2 . Feinberg ,

“ Ueber Reflexlahmungen : eine e'

perimentel le Studie," Berl. Klin . 187 1 , 49 1 . Bumke, “ Ueb er Refle‘

lahmung”

(two cases o f traumatic paralys is ), V irch . lii, 44 2 . Burow , D

Parese der animalen Nerven ,

” ‘Berl . Klin. Wo ch 187 1 , 600 . Ogle, ( 1)“ Som

what unusual fo rm of Paralys is (woman, ast. 39, paralys is of extrem ities , afi‘

ec tc

s peech , tw itc h ing o f musc les o f face , intelligenc e intact, wh ite atro phy o f Optic nerve’

(2 ) Paraplegia in a Boy, set . 7 , c o nnec ted w i th Curvature o f the upper part o f tl

Do rsal Reg ion o f the Sp ine (3) Parap legia o f s ome s tanding, suddenly becominw o rse,

” ‘Med. Times and 187 1 , i , 39 . Re incke, E in Fa ll vo n Para lys

Arm lahm ungen nach Luxatio n des Oberark pfes ,Bernhardt, “ Beitrag zur difi'

c rentiellen Diagno seArch liv, 2 67. Panas ,“ De la Cause re

'

elle de la Paralys ie réputée Rdu nerf radial, ” ‘Bull . de l ’Ac ad. de xxxvi, 963 . Althaus , “ On

the Brach ia l P lexus, ” ‘Med .-Ch ir. liv

, 14 5 . Kraft-Eh ing ,

“ U

l ahmung von Arm -nerven durch Kruckengehrauc h ,” ‘Deut. ix,

sh ire, Fac ia l Paralys is from Frigh t, ” Lancet, ’ 187 1 , i, 23 1 . Rus sell,o f lo c al Paralys is ; in two ac com panying disease o f the centra l o rgans o f

Cereb ellum (woman,

Fleischm ann ,

“ Ueberiv, 2 83 .

Disease by Diso rderedStOrungen nach Nerve

145 . S chiefi'

erdecker,

(E DEMA GLOTTIDIS, LARYNGISMUS, E TC . 101

Arch . f . Psych ii i, 433 . Beck, Sp indle-c elled Sarc om a c onnec ted w ith the Po s

terio r Tib ial Nerve, ” ‘Trans . Path . xxn , 18. E mm ingh aus,“ Ueb er h alb s eitiger

Ges ichtsatro ph ie, ” ‘Deut. xi, 96. Handfield Jones, E p ilepsy and o ther

Nervo us Afi'

ec tions resulting from the E xces s ive U se o f Alc oho l, ” ‘Practitioner, ’ 1872 ,Feb . W ilks, “ Alc oho lic Paraplegia, ” Lanc et, ’ 1872 , i, 3 2 0 . Lo ckhart Clarke,“ Alc oh o lic Pares is and Parap legia, ih ., 4 2 7 . Mo xo n,

“ A Case o f Parap legia la stingfive years, elec trical anaesthes ia, questio n o f m alingering (b oy, set. ih .,

ii, 7.

Benedikt, Nekro sc Opischer Befund b ei einem geheilten Fall von Parap legie,W ien . Med. Wo ch 1872 , No . 1 , 810. Gray, Sudden Decrease in the Frequency of

the Pulse during Disease a s a s ign Of appro ach ing Cerebra l Complic ation,

” ‘Brit .

Med . J 187 1 , ii, 94 . M itch ell, “ On th e Growth of the Nai ls as a Progno sticIndicatio n in Cereb ral Paralys is ”

(two c ases ),‘Am er. Jo urn . Med . lxi, 4 2 0 .

E des ,“ Mo rb id Growth s c o nnected w ith the Nervous System Cerebrum

,Cerebellum ,

and Sem ilunar Gangl ion o f the Sym pathetic , ih ., 87. Meade,

“ E xten s ive Depo s it o fLymph on Serous Memb ranes (Of bra in in b oy, act. 6 years, w ith fractured parietalb o ne, &c .) in n ineteen hours , ” Lancet, ’ 187 1 , ii, 13 . Dow se,

“ Cereb ro -sp inal Arachnitis, w ith Cerebral Disturb ance (w om an , set. 2 5 , auto psy), ih . , 1872 , II, 9 . Charpy,“ De la Defin ition An atom ique et Physio logique de la Paralys ie Générale, ” ‘Lyo n

ix , 78. Howden,

“ An An alys is o f the Po st-m o rtem Appearanc es in 2 35 InsanePerso ns ,

” ‘Jo urn . Ment. Wright, “ Insan ity Dependent on Constitutional Syph ilis , ” ‘E din . xvii, 1095 . West,

“ On som e Diso rders o f theNervous System in Ch ildho od, ” ‘Lum leian Lectures, ’ 187 1 . Tigri, “ Sulle Anom aliee sul le Ma lattie del Cervell o e part i annes se, c ome causa pro ss ima del la a lienazionementale resultanze degli stud i anatom ic i eseguiti nel corso di’ 2 0 ann i, pub licati perguida del dissetto re di queste necro s eo pie,

”Ann . Univ . di c cxvi, 5 23 . Ron

cati,“ L

’Arsenico contre le Malattie Nervo se,”Ga z . Med . 1872 , 9 . Bailly,

Des Paral ys ies c on'

sécutives a quelques Maladies Aigues, ” Gaz . des 1872 , 93 .

C . D iseases of the Respiratory System .

E dema G lo ttidis,Laryngismus , &e.

Bo elt (‘Rec . de Mem de Med. xxvi

, 43) gives the fo llowingcase z—A so ldier, set. 29 , had two years befo re had an attack o f

which lasted two ho urs,and was fo llowed by (edema o f

and face . On May 1 1,1870 , he had ano ther suffo cativeo n the 4th ; on the 10th hisnext day the dyspnoea c om

in swallowing. There was c on

lo ttis , and arytenO-epiglo ttidean

s o lution o f n itrateht hand and upper

d lower lip . The

In the ab sence o f

isc o vered in an affec tion o f the heart o r kidneys,

the sudden o c currenc e o f the oedem a,which was unac

by any symptom s Of inflammation,to hyperaem ia due to

f the va scular bran ches o f the sympathetic n erves .

G la sg. Med. 187 1 , iii , 2 09) repro duc es an alreadycase o f laryngeal o bs truction

, preceded by erys ipelas , in a

2 1 . Tracheo tomy was perfo rmed, but the o bstruction stil lrs the c anula . He gives a sec o nd case o f theale

,set . 18

,attacked with typhus . N o thing

laryngo s c ope abo ut the epiglo ttis o r vo ca lc ords . The laryngeal Ob struction became s o severe that tracheo tomy wa sperfo rmed

,and the patient was relieved. Later, the o bstruction still re


maining,

trachea,

by swell ithe m irrc ircularbelow .

manentthe second case there was undoubted c on stitutional syphilis .

Johns o n (‘Brit . Med. 1871 , i . 469)o f the larynx In the fo llowing gro ups : Hysterica l laryngismus ;(2 ) laryngismus stridulus in children ; (3) laryngeal Spasm , due to

pres sure on the pneum ogastric o r recurrent nerves , by aneurism o r

oth er tho rac ic tum our ; and (4) that pro duced by the presence o f a

fo reign body, o r the inhalation Of irritating gases o r dust, o r by inflamm ation o f the laryngeal muc o us m embrane . He gives the case o f a

girl , aat. 2 2 , who suffered from the first cause . Chl o ral was prescribed Indo ses o f ten grains every six hours

,and the laryngea l strido r ceased.

T he aphonia which ac c ompanied it yielded to galvan ism .

experiments on five dogs and a

nerves . He finds that the su

m o to r function o f the larynx,

the musc les o f the vo cal c o rdsTa it, Laryngismus Stridulus ,

o tomie

vii, 59 . Fieber,Rehn,

Ch loralhydrat gegen Spasmus Glo ttidis, ” Jahrb . f. Kinderhe lk iv,

Dip ktkeria and Group .

Letzerich Berl . c ontinues to insisthis favo urite fungi as the o rigin o f diphtheria . After the en

the Spo res into the blo od and lymph a sec ondary c onstitutional

ns , nausea , apathy, c onstipatin itis . The urine is dim in ished in quantity, and o

and casts m ade up o f masses o f the fungu s (l)tender on pressure . Convuls ions o ften o c cur in

o f five years . His treatment c onsists in the usequarter o f an hour

,

104 REPORT ON PRACTICAL ME DICINE .

The fungus was found on th

else,and ino culation with it

the trachea Of twelve rabbitsmen c aused death in five byinfection . The po st-m o rteminflammation in the larynx

and c onnective tis sue around and

kidneys were highly hyperaem icdec ompo s ing animal substancestho se o f diphtheritic m embranes .

from men into animals,repr

ino culated into o ther animals ,and into different tis sues andwound, and severe c onstitutio

lo cal disease begins in o ne

the body. He insists uponand diphtheria ; the latter

Classen (‘Vireh . 111,2 60) gives an analysis o f

o f diphtheria treated by him at Ro sto ck,from O ctober

,

the end o f March,

1 870 . Thirty-seven were fatal : 2 7fo cation ,

from extension o f the affection to the respirato ry2 from capillary bro nchitis after tracheo tomy (a third c asecheotomy, in a child, rec o vered) , and 8 from exhaustion o r

po isoning. Thirty-eight were under the age o f 10 years,2 6 b

10 and 2 0,and 3 1 o ver 2 0 years . He considers the s o -ca lle

membranes to be only dead muc o usfind any o f Letzerich

’

s sp ores , &c .

ferent m odes o f treatment, and publio f affected vis ion in a b oy, set. 15 ,haem o rrhage into the sheath o f the Optic nerve.

Hutchinson Lancet,

’1871

DIPHTHERIA AND CROUP . 105

Kraft-E bing Deut . ix,1 2 3) gives the fo llowing c ontribution

to paralys is o c curring after diphtheria . A man,act . 30 , suffering from the

affection ,was attacked in the co urse o f a few days with a progres sive

paralys is gradually extending to all the extrem ities , leaving the bladderand rectum intac t. T he paralys is was ac c ompan ied by cutaneous andmuscular anmsthesia . In the c ourse o f fo ur

,o rfivem onths the symptom s

disappeared. At the end o f ab out twenty weeks the c ontrac tility o f themuscles was lo s t to faradisation , b ut n o rmal to galvanism . He lo o ksupon the case as ano ther pro o f o f the peripheral o rigin o f the paralys is indiphtheria . (Cf. Buhl

,

“ E iniges iiber Diphtherie,”

1871 ,

Giiterb o ck Vireh . 111, 5 2 3) rec o rds five cases o f subcutaneous

emphysema Oc curring in diphtheria without tracheo tomy . He agree scompletely with the views o f Virchow a s to the m o de o f its o c currence,and with Traube c on siders it a symptom o f interlo bular emphysema o f

the lung. It is rare, much rarer than that which takes place during o rafter tracheo tomy . The five cases

,like tho se given by Sachse, Bartels ,

andHueter, term inated fatally ; while in eight cases of emphysema o f

the skin after tracheo tomy three reco vered.

Kersey Brit . Med. J 187 1 , i , 566) describes an o utbreak o f

diphtheria (fo rty cases) in West Kent, without any apparent cause .

Some cases o c curred near the les ser Stour, o thers o n gro und nearly a

hundredfeet abo ve, and a m ile from the river. Four term inated fatally .

One case is given at length, in which the membrane was extensive,albumen present in great am ount, and there was paralys is o f the pharynx and o f ac commo dation ,

fo llowed, during c o nvales cence, by

paralysis o f the extrem ities and o f the m usc les o f the neck and back .

Greenhow described to the Clinical So c iety (ih .

,i, 488) a case o f

diphtherial paralysis in a female,aat. 2 6

,treated suc cessfully with

faradisation .

Underhill (ih . , 32 3) exhibited five tracheae on which tracheo tomy hadbeen perfo rmed fo r membrano us croup in children

, a thick layer beingpresent in all . Tracheo tomy do es no t seem to have been succes sfulat the Children ’

s Ho spital, Birm ingham ,having been perfo rmed eight

times between Sep t . 1870 and Feb . 1871—twice fo r c ro up fo llowm g

scarlet fever, and o nce fo r diphtheria, o nce fo r (edema o f the glo ttis fo llowing gangrene o f the tonsils in enteric fever

,and fo ur times fo r mem

bramons cro up , in each case with fatal result .G . Buc hanan (ih .

,2 17) ho lds that tracheo tomy is admis s ible o nly

in the sthenic fo rm o f these diseases , when o ther treatment has failed,and the tendency to death is from apn oea rather than exhaustion

, and

before the vital p owers are les sened by the struggle fo r breath . A c learindication fo r the operation is a well-marked and increas ing drawing-in

of the c o stal c artilages and interc o stal spaces, with a m oderately go o dpulse . He gives , in full, a case in which the tube was remo ved on the

eighth day, in a b oy o f six years and he adds a table (cf. ih ., 3 10) o f

thirty-nine cases in which he perfo rmed tracheo tomy—fourteen in croup,twenty-four in diphtheria , and one in which a chicken -bone had lodgedin the glo ttis ; twenty-six were fatal ; nineteen o f the Operations werein children under four years, two o f which were suc cessful ; and twenty


in children fo ur years and o ver,eleven o f which were suc cessful ;

thirds o f the who le , therefo re , were fatal .Co o per Fo rster (ih .

, 309) rec o rds a case o f suc ces s ful tracheo toma child o f eleven m o nths fo r croup . [He ad

formed tracheo tomy in a man , act. 80 , with malignant growth inlarynx ]Bell gives (ih . , 369) a succes sful case o f tracheo tomy in a chilseven m onths fo r c roup .

Co rdier Lyon ix, 9 2 ; and see discus sion o n this paper,

106) gives three c ases o f diphtheria , two fatal , in boys act . 7 , and one in

a girl, set. 5 , o n whom tracheo tomy was successfully perfo rmed, and thec anula remo ved on the tenth day.

O livier (‘Gaz . des 187 1 , 85 ) publishes two cases o f croup ;one was in a girl , set . 7 , in whom trac heo tomy was perfo rmed in

extremis , and the canula remo ved after seven days . T he daily temperatures , &c . ,

are given . T he o ther was in a b oy , act . 4 , who als orec o vered after tracheo tomy, the canula being rem o ved on the thirteenthday . In th is case there was laryngeal paralys is .

As to o ther m eans o f treatment in diphtheria,187 1 , No . 3 1) uses a s o lution o f brom i

brom ine (gr. vj to 3iv) fo r penc illingBrasch Ber. Klin . Wo ehr

,

’187 1 , 5 5 1 ) gives glycerin

ternally and carbo lic ac id lo cally . Under this treatment the inwas 2 0 per cent . , while under the employment of n itrate o f s il

m ercurials it was 5 7 per cent .Helfer (‘Deut . 187 1 , 2 29) Obta in s goo d results from

o f carbo lic ac id.

Bo uchut Gaz . des 187 1 , 3 2 6) uses injections o f a

o f co al tar and tinc ture o f saponine (coa ltar sap onine) , and ind

the children to allow it by giving sugar water in the same syringe .

gives a case (ih . , 582 ) where an emetic had go od effec t .Laserre Bull . de l ’Acad. de xxxv) found, when he

c alled in early enough ,a heated chamber, andsuc cessful results .

Bouchut Bull . ’ d

emetic c aused vom iting o f the false m embranes . The childreyears O ld o r younger, and the m edic ine was given in do ses 0two grains , acc ording to age, in two o unces o f sugar-water.when it was no t given as an emetic it was employed as a

stimulant . ” A grain was disso lved in two ounces o f water,teaspo onful s given every two hours . Thick soup or bread s

SO as to prevent the purging effects o f the tartar emetic .


30—45 sec onds

,and was succeeded by a c omplete pause o f 2 0

sec o nds , during which the pupil was c o ntracted and immo vable,again the sam e round o f symptoms was repeated He never lo sts ciousnes s . He was again seen in N o vember, 1870 ; the pec

respiration was still present, and a m o nth later the patient died.

auto psy is given , but neither it no r theo n the cause o f the phenom en on . The

the long perio d during which the peculiaWaldenburg Die Manometrie der

als diagno stiche Metho de, ” Berl . Klin .

diseases o f the lungs . The instrument proves what is already known,that in the no rmal state the pres sure o f expiration is stronger than thato f inspiratio n ,

the fo rmer averaging between 70 and 180 , o r even 2 00

m illimetres , the latter between 60 and 1 2 0 . The average o f the expirato ry pres sure in men is 80— 1 2 0

,o f the inspirato ry 70—100 ; in women

pressure o f expiration is n ormal , whilelow ; in the later stages , however, the expirato ry pres surenished. These facts may be used in the differentia ldisease . In cases o f stricture Of the trac hea bo th pdiminished.

KOrner (“ Beitrag zur Lehre von der

1871 , 189) refers to the detri

small development o f the

c o urse o f affections Oftion leads to defec tive

pro ces s o f cheesyso ftening is produced by the reabs o rption Of dead matter,usually pers ists in propo rtion to the extent and density o ftion which surrounds the cheesy depo sits and the vomicas.Brown -Sequard Lancet,’ 1871 , i , 6) gives the fo llowin

his experiments on guinea -

pigs , &c . Crushin

V ario lii caused numerous ec chym o ses,and c v

lungs, generally m o st m arked o n the s ide o pples ion . The

sympatheticvessels, als oappears printo Ranvier,s erum , and the m inute blo o d-vessels are filledwith white

,and free from

red,c o rpus c les . He states as a new fac t that emphysema o f the lungs

c an appear when no t a Single respirato ry m o vement takes place, afteran irritation o f the base o f the brain

, either by crushing o r cutting.

”

He draws attention to the frequency o f pulm o nary changes dependento n brain-influence. Of 188 cases o f organic diseas e o f the brain, red

MEDIASTINAL GROWTHS . 109

c orded by Calmeil,there was a m orbid c ondition o f the lungs , especially

inflammation ,in m o re than 60

,i . e . in 1 o ut o f 3 .

Wh itehead Trans . Path . xxii, 82 ) showed some peculiarsputa “ hawked up

”after eating by a woman

, act. 2 4. T he spu tum

c ons isted o f tenac io us, gelatinous -lo oking m as ses

,m o re o r less elo n

gated, o f ragged o utline,and non - tubular

,and o f delicate , transparent,

membranous laminae, varying in s ize from that o f a m inute flake to a

square inch , and streakedW Ith irregular reticulations . The m icro scopeshowed that b o th were alm o st entirely m ade up o f stratified squamous

epithelium ,with a few muc o us c o rpusc les . These charac ters favo ur the

Opin io n that the spec imen c o ns is ted o f mucus yielded by a catarrhalc ondition o f the pharynx o r upper part o f the oesophagus .Baas, E xperimenteller Beitrag zu Aufkltirung derFrage uber den E ntstehungso rt

und die E ntstehungsart des sog . Ves icular-Athm ens und der Rasselgeraus che,” ‘Deut.

ix, 3 16. Lippe, Grenzen des no rm alen Bronchialathm ens,”ih ., 5 2 5 . Rehu,

Zwei Beo bachtungen vo n Cheyne-Stokes ’ s chen Respiratio ns -phanomen b ei Lungenaflec tionen im kindlichen Alter, ” Jahrb . f. iv, 43 2 . Leven, “ Des

diverses form es d’Asphyxie au p o int de vue phys io logique et patho logique, ” Gaz . des

1872 , 68. Bo urgeo is , De la Congestion Pulm ona ire s imp le,’ Paris . Rohden ,

Der Zweckmas sigste Geradhalter,” ‘Berl . Klin. 187 1, 2 36. Watts,

‘Inha

la tion for Diseases o f the Lungs, ’ London .

Medias tina l Growths .

Virchow Archiv, ’ liii , 444) describes a peculiar mediastinal tumour(Teratoma myomato des) . The patient, a man , act. 2 2 , had been under

Observatio n fo r abo ut two m o nths . He had been indispo sed fo r s ome

weeks,and c ompla ined Of sho rtnes s o f breath and pain in the right

tho rax . On percu s s io n there was dulnes s from the third right ribdownwards , extending in an Oblique line backwards to the angle o f the

scapula . NO respirato ry m urmur wa s audible o ver this region o f dul

ness . The general c onditio n Of the patient became gradually wo rse,with febrile symptom s from time to time . After four o r five weeks a

painful prom inen ce began to b e develo ped at the junction o f the cartilage and bo ne o f the left rib . In abo ut five weeks , when death o c curred,this tum o ur had reac hed the s ize o f a small fist. At the same time thedulnes s on the right side became greater in front as well as behind ; theliver was pushed down . Fo r s ome tim e there was oedema o f the rightside and part o f the abdom en

, which gradually disappeared. Deatho c curred from in creasing difficulty o f breathing. T he diagno sis made

was an encysted exudation in the anterio r po rtion o f the pleura . The

tum our on the third rib was c ons idered to be a c o ld absc es s ” o r an

enchondroma . T he auto psy showed an elastic tumo ur, which had destroyed the anterio r part o f the third rib . Instead o f any pleuriticexudation was found an eno rm o us tumour

,which o ccupied the greater

part o f the right tho rax, and extended s ome way o ver the m iddle lineto the left . T he right lung was pushed backwards and upwards , theheart to the left, and the liver downwards . The latter was greatly enlarged, and c o ntained vario us hard nodes , some imbedded in its sub

stance, some prominent on its surface . The spleen was enlarged, andpresented on its upper surface several vesic les, about the s ize o f a wal


nut, and c ontaining blo o dy fluid. The kidneys were also enlarged, andconta ined the same kind o f nodes a s the liver. On ac c ount Of the ad

vanced decompo sition it was impo ssible to m ake any further exam ination Of these three o rgans . The m ediastinal tum our was 2 0 cm . lo ng,2 1 bro ad

,and 13 thick, adherent to the right lung, the pericardium ,

and

the large ves sels . The left and larger po rtion o f it was almo st co mpletely so lid, richly vas cular in parts , b ut distinc tly fibrous . In the

fibrillar intervening substance were numerous SpIndle-Shaped cells ,

like tho se o f spindle-celled sarcoma ; but the chief m as s c o nsisted o f

o bliquely s triated sp indle-cells, c ontaining o ne o r m o re large nuc lei .The Older elements were striated thro ughout their who le thickness , theyounger only o n the surface (Virchow ’s Myoma strio cellulare) . Theirderivation from no rmal musc le was impo s s ible, as the cells had do ublepro longation s , like the branched musc le-cells Of the heart . T he rightand smaller half o f the tumo ur c onsisted o f small cysts

,about 2 5 cm . in

diameter,c ontaining on their inner surface small o utgrowths and ves i

c les , like tho se fo und in pro liferating o varian cysts . In many p lacesthe cysts were c onfluent . In the m iddle Of the tum our was a cavity ,2 5 by 15 cm . , which was surrounded by a leathery wall and enclo sedhair, small plates o f epiderm is , cho lestearin ,

and fat . Other cavitieswere lined with c iliated epithelium . In the neighbo urho o d were smalls cattered po rtions Of hyaline cartilage, with a thick pericho ndrium ,

ex

tremely like the c artilages Of the bronchi, tho ugh no c onnec tion betweenthe two c o uld b e made o ut . In one place the tissue was finely spongy,and in the meshes were ro undish

, granular, nuc leated cells, like gland-bc ells

,the strom a being m ade up o f sarc omato us round and sp indle

cells . In the tumour on the rib were cysts,striated musc le-cells, and

patches Of c arc inoma . One patch , the s ize o f a hemp-seed,c o ns isted o f

round alveo li made up o f elastic fibres,like fuatal lung. This tumour

was entirely surrounded by perichondrium,and was no t c onnected with

that in the mediastinum .

The variety Of elements entering into the fo rmation o f this growthpo ints to a foetal o rigin . The c iliated epithelium and cartilages in thelarge tumour and the elastic fibro us netwo rk in the small recallSO vividly the o rgans Of res

piration that the m ind i s c ompelled to

think o f an aberra tion o f partie es , which o riginall belonged to bronchiand lungs . ” Still

,there is a difficulty in ho lding t is view in the face o f

the fac t that the greater part o f the large growth, and the who le o f the

small one,was developed during the latter part o f the patient ’ s life .

We must therefo re, espec ially with regard to the tumours in the ah

dominal glands,c onsider it as a hetero chronous , metastatic growth .

”

The paper c onc ludes with remarks on derm o id cysts Of the mediastinumand their po ssible starting-po ints, and on lymphO

-sarcomata (thymus,bro nchial glands , skin) .

Gueneau de Mussy Gaz . viii, 462 , writes a long paper

on Bronchial Aden opathy in the Adult . ” He lo oks upon this affec tiono f the bronchial glands a s sec ondary, and fo llowing les io n in o rgans

traversed by the lymphatic vessels which feed them ; under the influenceOf c onstitutional predispo sition they a cquire such develo pment as to

bec ome the predominant element in the disease ; in some cases they


lung was c ontracted and adherent to the growth . The

glands were much enlarged ; several masses Of c ancer werethe liver and pancreas .Risdon Bennett, ‘Cancerous and o ther

'

Intrathora c ic Growth s , the

Histo ry and Diagno s is, pp . 190, L ondon, 1872 . Ho rstmann ,

‘Drei FalleMediastinaltum or,

’Inang. D iss .,

Berlin . Po hn,

‘Besch re ibung eines Fall esDermo idcyste des Medias tinum antic um ,

’Inaug. Diss . , Berlin .

P leurisy, fl“ :

Huss Ueber den anderseitigen pleuritischen Schmerz , ” ‘Dix

, 2 42 ) attempts to find an anatom ical explanation fo r

c ases in which pain o c curs o n the side o ppo s ite topleurisy . Laennec firs t des cribed cases in which thewhere than o n the affec ted s ide . Andral challengedthese o bservations ; Wintrich has al

Various writers have, however, no ticed thebeing able to give any explanation o f it . G

by him ,in which the patient c omplained o f

the sternum ,while the pleuritic rub was to

side, assumed the exis tence Of anastomo senerves in the anterio r mediastinum . Hus s

Handfield Jones Brit. Med. J 187 1 , i , I39lec ture o n a case o f efl

'

usion into the left pleura , in an

on whom paracentesis was perfo rmed on the twentiethm is sion into ho spital , about eighty-six o unces o f fluidT he patient had as c ites at

appeared on his dis charge . In s ome remarks on the caseallows that the presence o f weak and distant breathing o n

s ide Should no t cause a po stpo nement o f the Operation ,

o c cas ioned here, “ fo r lung-s ounds can penetrate thro ughthickness o f fluid .

Redenbacher (‘Deut . Arch ix

,2 40) rec o rds the fo llowin

set. 6, previously healthy, had been fo r four weeks sufferingdant and increas ing effus ion in the right pleura . He had bw ith quinine and iron

,but had rapidly lo st fles

then perfo rmed. Mo re than two pints o f pus weremediate relief to the patient . The cavity was washwith lukewarm water. The canula was taken o ut o n the

day. A month later the patient was greatly impro ved inthere was no difference, either in measurement o r respiratoon the two sides .Paul De la Thoracentese , c omme méthode de traitement

réSIe Aigue, ” Bull . Gen . de lxxxi,83)

a cute.pleurisy in patients between the ages o f

practised paracentes is with suc cess .

PLEURISY , E TC ; 113

exit, it may be pretty certainly assumed that the effusion willcur, o r if it do es reo c cur will do s o in s o small a quantity as toreabsorbed .

Béhier gives a lecture (‘Gaz . des HOp . ,187 1 , 349) on a case o f

on the left side, in a man,act. 2 6 . His views are

as Paul ’ s . T he dangers caused by the effusion he

o f the heart,and the hindrance thus placed

the fluid ; when the o pp o s ite lung is attackedo ther affection preventing its full and no rmalre is any reas on to suppo se a tendency to tubere perio d at which the o peration should b e perthe n inth o r eleventh day o f the affection ; in

1 symptom s Of inflammatio n have sub

ade in cases Of necessity,when it should

Of the effusion .

es o f o perating in casesHe him self prefers

sp . 11,69) reviews the literature Of

gives tables o f cases observed by differentHe ins ists upon an early evacuation o f the

inc lines to the view that the sudden death , by noin cases o f pleuritic effusion , i s due to co agulation o f

onary artery .

Various papers discussing the propriety Of tapping in pleurisy andempyema , by Fuller, Priestley , Do uglas Powell , and Others

,m ay be

found in the first vo lume o f the ‘Brit . Med. Journ .

’

fo r 1872 . The

papers placed in the bibliography o f this subjec t are suffic ient pro of ofthe interest taken by French writers in paracentesis .

1872 , i , 583) rec o rds a case Of pleuriticsailo r, act. 2 4 , o n wh om p aracentesis was

in its outer and upper surface .

chements de la Plévre,” ‘Réc . de

at length , the report o f a caseman

,act. 2 1 . On the thirteenth

perfo rmed the same day, and

T he heart, which had beenal po s ition ; resonance and

and front part o f the thorax .

8


Some days later,after a rigo r and persistently high temperature, tt

effusion returned, and ano ther o peration rem o ved 2 100 grammes 4

o palescent fluid containing a few flo c culi. A drainage tube was keyin the wo und after a third withdrawal o f pus ; the Open ing we

enlarged and the c avity washed o ut with io dine and alc oho l , the panlysis o f the right s ide gradually disappeared, b ut the patient died 1

length of exhaustion . At the autopsy the left p leural c avity formed a

eno rmous purulent sac ; the heart c ontained only recent c lo ts ; the lec orpus striatum was softened, and two branches o f the m iddle cerebr.artery were obliterated by a c ompac t mass o f the cons istence an

co lo ur o f wax, the blo od-vessels being completely healthy . He 1001

upon this as an emb o lus detached from one Of the cavities Of the hearand supports his theory by the fac t that about the time at which thapoplectic fit o ccurred a gangreno us patch appeared on the right fo odue

, probably, to the same cause. He remarks on the rarity o f th'

c ase,and is able to find only two o ther similar ones . The first

rec orded by Po tain Bull . de la So c . 186 1,

In this casthat o f an elderly woman

,who was attacked suddenly with hemiplegi

during an acute attack Of pleurisy, and died in twenty-four ho urs, thanterio r cerebral artery was found o bliterated, and the heart co ntaineOld c lo ts . The second c ase was published by Robinson (‘Army Mei

Rep .

’fo r Here, in a s o ldier

,set. 2 2

,also suffering from pleuriti

effusion,paralysis Of the left side

, o c curring ab out two months befOIdeath

,was c onnected with softening Of the right c orpus striatum .

Renault Union xii , 2 9 1 ) reco rds the case o f a man, aet . z junder the care of Besnier. T he patient had effusion on the right Sldland died suddenly in his bed. The autopsy showed a large fibrinOI

c lo t,c ompletely filling the right auric le, extending into the ventricl

and pulmonary artery . The cerebra l arteries were perfectly health]Besnier

,who had purpo sely deferred an Operation, c onc ludes that in a

cases in which there is c onsiderable efl'

usion,on the right side as we

as the left, thoracentesis ought to b e perfo rmed as promptly a

po ssible . Death was due in this case,he thinks

,to general arrest <

1 .

the line o f the co stal cartilages, generally likewise down the

Spending side Of the abdomen , o ccasionally upwards to the tipshoulder, and aggravated by movement of body, full breathing,and vom iting .

2 . Shallow and tho rac ic breathing, dorsal decubitus , andrative freedom from pain in that state o f res t .3 . Absence o f febrile action in m ild cases uncomplicated by

p leuritis , pneumonia, perihepatitis , o r o ther fo rm o f acute intion ; and in severe c ases

, whether c omplicated or no t, syc o llapse .

4 . Partial o r complete suspension o f respir

116 RE PORT on PRACTICAL MEDICINE .

Laffan , “ Ob servations i llustrative Of ' th e Use Of Dieula foy’s Pneumatic‘Dub l . Quart. l iii, 2 0 2 . Fitzmaurice, “ Cases Of E ifusion into the Cih., 111, 388.

Bronchitis and E mp hysema .

Julian (‘New Y ork Med. vi, 3 57) thinks that the indiein suffo cative cap rid o f the

materia

o f zinc and tincture o f sanguact. 6 to 18 months, do ses Ofdro ps Of the tincture everylater perio d and the maladyfrom three to thirty dro ps Ofhours, regardless o f vom iting. He quo tes thin a state o f c o llapse, and to whom he appli

Isaakson (‘Vireh . lii

, 466) hasvessels in emphysema . He finds themstretched instead Of winding ; several infilled with thrombi and no t a llowing the

After the injection Of silver so lution, thethel ium was absent in the earliest stagefinely granular

,lined with white blo od

starting-po ints Of c o agulation and c ompleThese p ortions underwent fatty ch

He c onsiders this destruc tion o f the vessels to beemphysema .

Berkart Lancet, ’ 187 1 , II, 745) describes an

has used with the best results in emphysema, andaction o f a pump , withdrawing air at the end

increases the abno rmally lessened expirato ry poweHertel Berl . Klin . 187 1

the resonance Of the In

nummular sputa, cyansomno lence, and the pdiagno sis was as fo llowsprobably with bronchietrue vesicular emphysema ; dilatation and

ventric le ; fatty degeneration o f the rightto Traube’s experience, is always presenttion Of the lungs is ac c ompanied by persiste

cus s

diagno sis Of catarrhal inflammation o f the hrThe doub le diasto lic sound he explains by the hypertro phy o fauricle, and the c on sequent s tretching o f the tricuspid valve,c onsiders to b e far from unc ommon .

De Savignac , “ Séric s des Fo rmules pour le Tra itement de la Bronch iGen . de xxxi, 2 5 2 . Decayeux,

“ Les Fiévres Catarrhales ”

(an

BRONCHITIS—ASTHMA—WHOOPING-COUGH. 117

ment o f the Syrup o f Peter Lamouroux), Gaz . des 187 1 , 5 10 . Laffan , Lo calBleeding in th e Dilated Right Ventric le Of Chron ic Bro nch itis, ” Brit. Med. J1872 , i, 1 28. Greenh ow, Lungs from a Case o f Cured Phth isis, Death from

Cap illary Bro nch itis , Cavities lined w ith False Mem b rane in b o th Lungs, Pro liferation o f Interlob ular Connective Tissue, and great th icken ing of the P leura ”

(m an,

set.‘Path . So c . xxi ii, 47. W ilks , Bleeding in Emphysema and Bron

chitis”

(woman , set. 60 , relief) , Lancet,’ 1872 , i, 88. Leyden, Tyro s in iu Sputumgirl, w ith putrid bronch itis), Vireh . IV , 2 39. Neureutter,

“ Bronch iektas ieund h o chgradiges Emphysem als Compensation b ei einem s ieb en Jahr alten Knaben, ”‘Oesterr. Jab rb . f. Paediatrik,

’1872 , 18.

B ronchial Asthma .

Leyden (‘Zur Kenntniss des Asthma Bronchiale,’ Ro sto ck, 187 1)describes a peculiar expecto ration o ccurring in bron chial as thma. It isscanty, very tenacious, and transparent . It c ontains a mas s o f fila

ments and flakes, some very m arked from their thicknes s and yellowc o lour. They are brought up from the finest bronchi, and c ontain intheir meshes granular m ucus -corpusc les , and generally a large q uantityo f very beautiful and p eculiar crystals , of an elongated o ctahedral form .

The largest are visible under a power Of 300 diameters,the smallest

under one o f 600 . Crystals o f the same kind have been described byFriedreich in croup ous bronchitis , and they are probably identical withtho se found by E . Neumann in the medulla o f the bones . In the

blo od Of leuchaemic patients Leyden thinks that these crystals mayact as mechan ical o r chemical irritants on the peripheral ends o f thepneumogastric in the muc ous m embrane

,and provoke reflex contraction

of the muscles of the small bronchi .Weber,

“ Da s Aub ree sche Geh eimm ittel gegen Asthma Nervo sum ,

”Deut. Arch

viii, 2 1 7. Lessdo rf,“ Asthm a No cturnum Periodicum . Mo rph ium Injection Palli

ativm ittel ; Comprimirte Luft Radicalmittel ,” ‘Deut. 187 1 , 15 . Anstie

,

On the Path o logical and Therapeutical Relations o f Asthma, Ang ina Pectoris, andGastralgia, ” ‘Brit. Med. 187 1, ii, 5 50 . Gask o in ,

“ On the Treatment o f

Asthma ,”ib ., 1872 , i, 339 . T horowgo od,

“ A few Remarks on the Treatment ofAsthma,

” Med. Press and 1872 , i, 2 7 .

Whoop ing-cough.

Steffen Jahrb . f. iv, 4 2 7) confirm s the go o d resultsObtained by the employment o f quinine in who oping-cough , as firstpo inted out by Binz , and verified by Breidenbach . In the m aj ority o f

cases he found it work speedily and readily,failing o nly in a few . He

employed pretty strong do ses, half to o ne gramme in the twenty-fourhours

,in ch ildren from two to five years . He gives two cases in full .

In a case o f a child o f three years, who c ould no t b e go t to take thedrug

,he used injections for the purpo se. In three days n ine injections

,

containing altogether two grammes Of quinine, were given, with alleviation Of the symptoms .MacCall G lasgow Med. 187 1 , iii , 162 ) during the winter o f

1869-70 found ul ceration o f the fraenum linguae in 1 1 1 out Of 2 5 2

children attacked with who op ing- c ough , o r in about 44 per c ent . Theaffection varied in degree from a m ere abrasion to a deep fissure w ith agrey o r yellowish surface, and often b leeding during or after a

118 nnronr O‘

N PRACTICAL MEDICINE .

aroxysm . In 105 out o f the 1 1 1 it was situated in front of theaenum ; in four out o f the o ther six its varying p o sition was aec om

panied by some abnormal disp o sition o f certain teeth . He c ons iders itto be due to the rubbing o f the tongue against the latter in the act o f

coughing. He lo oks upon it as a valuable diagno stic sign in cases Mwhich the c ough is no t heard at the time when the patient is seen .

Prestw ich , “ Cod-liver Oil in Who op ing-co ugh , ” Lancet,’ 187 1 , n, 8 1 2 . Murray,“ E xtract o f Nettles in Who op ing-c ough , ih ., 1872 , i , 539 . Grantham , E ffects ofthe Vapour o f Ammonia in the Treatment o fWho op ing-cough ,

” Brit. Med. J1871, ii, 323.

P neumonia .

Revillout Gaz . des 187 1 , 2 73) discusses the questionwhether pneumonia is a disease having a defined course and type

,and

whether it be true, as Jacc oud affirm s Traité de Patho lo gie Interne,"

Paris, 187 1 , ii) that it canno t be abridged a single hour. He lo oksat the affection from the po int o f view o f o ther diseases

,6 . g . albu

minuria , syphilis, &c . , and c o nc ludes that the ho lding o f any such viewtransfo rm s the physic ian into a fatalist transfo rme en un Musulman

dans le sens Arabe et préc is de cette expressionFarquharson (‘E din . xvi

, 988) brings fo rward ten cases insupport of his view as oppo sed to tho se o f Trous seau

,Hughes Bennett;

and Sturges, which c onvince him o f a spec ial lowering o f vitality whichalmo st invariably attends extension o f inflammation to the apex

either lung. In some remarks on the treatment o f pneumoniagives a single case in which he thinks aconite cured an extremdoubtful (Rep ) c ase o f the affection .

Fitzmaurice (‘Dublin Quart . J In, 386) c onc ludes from

own observation that pneumonia in children and infants,and in

cases in which chest symptom s are absent, i s o ften m istaken fo ra ilments , as dentition ,

wo rms,&c . He considers the law as laid

By keepingplace (after co f tubular brthe child.

”

disease ; andair m o re effectually than simple dressing . He givesillustrate his p o sition . The fourth cas e

,which he seem s to have

upon a s croup,b e “ cured ” by giving large do ses o f deco ct

senega .

’is

Sturges ( “ The E tio logy o f Pneumonia , ” St. George’s Ho sp .

v, 135) writes on the general influence o f the weather upon the so

inflammatory diseases o f the chest . Taking the average o f ten

if Croupy c ough and laryngeal stridor are more frequently than is genermitted thc forerunners of s imple bronch itis in ch ildren.

—A. B . S .


o f the legs , but after death varic o se veins , which had been o verlo okedduring life, were disc o vered on them . In addition to

,

the signs o f thelobar pneum onia in c ourse o f reso lution, and some S ign s o f o ld lungm ischief, there were found seated upon and extending from the bifurcation o f the pulmonary artery into h

its differen t bran ches a number o f

c lo ts , n on -adherent to the walls o f the ves sels, and showing impress ionso f venous valves . Clo ts o f the same kind were found in the varic o seveins

, espec ially on the right side the walls o f these ves sels were perfectly healthy , excepting the u sual changes fo und in such vem sg

E xcept when they were entangl

quite free . The embo li in the

tions o f these c lo ts,formedwithe

and detached by the muscularb ed . Hayem refers to a c ase o f the sam e kind which hthe prac tice o f Tardieu in 1868. But in the latter thewere inflamed, and were fel t as hard c ords , and easilyc o agulation which led to the same fatal result .Mo xon Path . So c . xxii

, 38) describes a pe

and c o ated with recent firm lymph ;po rtion showed a state o f grey fibro idand hardening and darkening o f the tia ll the lower lo be, and spread with an

T he right lung showed large patchesThe vo cal c ords were thick . The

c ontained c icatric ial patches likekidneys

,

o f chests cepical

death , but Mo xon c onc ludes , from the presence o f markedsyphilis, that the p leurisy and pneum onia were syphilitic .

Green (“ Interstitial Pneumon ia

,

”ih . ,

xxiii, 39) rec o rds the

an ce found in the lungs o f a man act. 60,who suffered from

bronchitis and died o f an acute attack o f that affec tion . The ri

pigmented and tougher than natural . T he kidneys were 8

indurated. The m icro sc o pe showed a growth o f fibre -nuc leatedround the bronchi and blo o d-vessels

,affecting also the alveo li .

Brouardel (see‘La-neet

,

’1872 , ii , 493) draws attention to th

rap id fo rmation o f interstitial pneum onia and o f false m embranes ,reduce the s ize o f the lung and form an obstacleand c on sequently the harmlessness o f early, and

paracentesis .Strohl (‘Union xi

,134) has been using

neutral acetate o f

to do so in 184 1

PNEUMONIA-L—nrrnnrao rnr . 121

antimony, and blisters, had a return o f the affection on go ing back towork to o so on ,

and in whom a recurren ce to the same treatment wasimpo ssible . Rapid rec o very fo llowed the exhibition o f the lead in do seso f five, increased to fifteen centigramm es , in the day . He next appliedit to cases o f the disease in o ld and feeble p eo ple, in whom the

hero ic treatment abo ve m entioned had had n o effect o r c ould no t

be resorted to ; and lastly, he employed the drug in cases of pneumoniao ccurring in all ages . He publishes in full 14 out o f 33 cases . The

mortality was o ver 10 per cent . The average period of the pneumonia,

dating from the c ommencement to the ces sation o f the physical signs ,as revealed by the stetho scope, was 10 2 3 days .Papillaud,

“ Du Tra itemen t de la Pneum on ie, ” ‘Gaz . 187 1 , 3 1 2 . Mo s ler,Ueberb iliose Pneum on ie und dadurch c omplic irten Typhus recurrens ,”x, 266. Al t,

“ Ueb er die Beh andlung des crouposen Pneumon ie m it Veratrin ”

(w ithcurves o f pulse and temperature of three cases, b es ides one in th e text twenty-o ne

cases given alto geth er), ib . , ix, 1 29 . Weigand, Zur Pneum o niefrage,” ‘Berl . Klin .

1872 , 6. L ieb ig, Behandlung der Chronisch en c atarrhal ischen Pneumon iem it erh ohtem Luftdruck ,” W ien . Med. W o ch 187 1 , No . 2 0 . Moxo n ,

“ AcuteInterstitial Pneum o nia, ” ‘Lancet,’ 1872 , ii , 779 . W illiam s ,

“ Pneum on ia , ” ‘Med .

Times and 1872 , i , 1 2 1 . Read , Oxygen in Diseases of the Lungs ” (s ixteen cases

o f phth is is , acute and ch ron ic pneum onia , and chron ic b ronch itis, in wh ich the gaswas used regularly, and fo r a suffi c ient time to warrant the drawing of a conclus ionas to its effec ts), New Y ork Med . J xiv, 382 .

Brown Induration andHyp ertrofl zy .

Delafield Amer. Jo urn . Med. lxi, 95 ) reco rds his observations

on“

pigment induration ”o f the lungs , based o n twenty autopsies , in

which he fo und this change in c onnec tion with disease o f the heart.The lungs are small, their lobes adherent to one ano ther and in

part to the c o stal wall ; the pulmonary pleura thick and Opaque . Onsection the lung-tis sue is resistent, very dry, c ontaining s carcely anyair

,blo od

,or serum . T he m icro scope revealed ( 1) new p igment, (2 )

hypertro phy o f the walls o f the air- cells , 3) dilatation o f the capil

laries,and (4) a marked increase o f c ellular elements within the

alveo li . An analysis o f the cases shows that m itral steno sis is alm o stalways accompan ied by pigment induration o f the lungs ; that simplemitral insuflieiency causes it in nearly half the cases ; and that aorticdisease causes it in one fourth . A full analysis , with tables, is given ofthe po st-m o rtem appearances in the o ther viscera, &c .

Rindfleisch Central blatt,’187 2 , 65) writes on the muscular tissue

of the smaller bronchi, which bec omes much hypertrophied in the se

called brown induration o f the lungs . He describes a peculiar anddistinct layer o f c ircular muscular fibres as surrounding the smallestbronchi , form ing a kind o f sphincter where they open o ut into theinfundibula ; these c ircular fibres send 100ps into the openings o f thelatter

,which are als o surrounded by smo o th muscular fibres . These

fibres may be easily made out in the normal lung by tho se who haveobserved them in the hypertrophied c ondition .

Thierfelder,“ E in eigenthum licher Fall von Hypertroph ie und epithelialerHepatisation der Lungen,” Deut. x, 2 09.

122 REPORT ON raxcrmxt nnnrcmn.

Gangrene and Abscess .

Senator ( “ E in Fall von Lungenab cess mit‘

a llgemeinem Haul

emphysem ,

” Vireh . liv, 2 78) publishes a case o f ab s cess o f thlung supervening on pneumon ia, breaking through into the subenteneo ns tissue and causing general sub cutaneous emphysema . The lattec ame on suddenly and with great rap idity, and was due

, according tthe patient , to vio lent crying out. T he auto psy revealed a c avity ithe p o sterio r part o f the left lower lo be, about the size o f a fist

,an

filled with purulent fluid. T he p leura and layer o f musc les whiol im ited it were ecchymo sed, ro tten ,

and b oggy. A sound c o uld easil

be passed from it in severa l directions into the pleural cavity .

Salkowski (‘Berl . Kl in . 187 1 , 169 ) writes on this rare an

little known affectio n ,and gives a case, o ccurring in Leyden

c lin ique, in which abscess fo llowed an attack o f croup ous pneum on'

o f the right lower lobe . The patient was an ill-conditioned man

49, who had been a drinker. T he dulnes s c leared up with al l sym

toms o f a crisis on the eighth day ; next evening a fresh attackpyrexia o ccurred, with tearing c ough and abundant

,thick, purifo r

sputa . On the fifteenth day shreds o f lung-t issue were found inunder the m icro scope, which gradually increased in amount and in sizreaching the length o f an inch . A m onth after the first c ommenu

ment o f the affection these shreds were found fo r the last time ; tsputa altered in character, became muco -

purulent, and lastly diappeared. About the same time the tho rax sank in

,the gener

c ondition o f the patient impro ved, and on the fiftieth day he left ablewo rk . The diagno sis o f lung abscess is based espec ially o n the spa tzthe temporary presence o f shreds o f lung-tissue , the absence of sigr

o f decompo sition or fungus spores , prevent its being c onfounded wi

gangrene ; the ac companying symptom s leave o ut o f question tp o ss ibility o f phthisis, in which affec tion ,

also,the elastic fibres may

fo und. The treatment c ons isted o f inhalation and exhibition o f ca

b o lic ac id, quinine, c od-liver o il,and wine .

Waring-Curran 1872 , ii, 669) gives a. somewhat doubtfc ase o f abscess o f the right lung bursting thro ugh the diaphragm ar

umbilic us . The b oy is still alive ; in February, 187 1 , he had typhofever, fo llowed by pneum onia ; in September, 1872 , a swelling a

peared under the edge o f the ensifo rm cartilage, which , fo ur days latehad m o ved, and was lower down, to the right, in the sheath o f t

rectus musc le.

”Next day this swell ing burst and gave exit to a

enormous quantity o f o ffens ive pus .

Leared (ib . ,187 1 , 11, 4 7) rec o rds the o ccurrence of gangrene o f t

right lung in an intemperate man, set. 49 , who had fallen from a heigo f eight feet into the water

, and had been submerged twice . I]

quo tes two cases as o c curring after immersion in water out o f focases o f gangrene o f the lung rec orded by Sto kes

, and a case mentioneby Lankester in which gangrene fo llowed the repeated dashing of co lwater o ver a woman p o isoned by o pium . Death o ccurred in Learedcase thirty-five days after immersion . T he temperatures taken we]

remarkable for sudden o scillations .


free, sometimes enclo sed in cells . In the sec ond case the pwas working in an ultramarine manufacto ry, and had presentedweeks before death the symptoms o f typho id. death thewere found filled w ith foreign partic les , butenteric fever. T he th ird c ase was one

a man o f 2 9 , had wo rked fo r six yearsand had inhaled the fine partic les o f o xideyears he had ceased to work at his trade .

t ion showed, in addition to a cavity about thshrinking, induration ,

and c o louro f iron . T he fourth case was onethe pigmented c ondition o f

'

the

tuberculo sis (lungs, kidneys , anTraube’s phthis is m elano tica . Ihad been o b served during life,marine m anufacto ry, pres entedbluish-black fluid mass

,made up o f

crystals, &c .

Risdon Bennett Path . S o c . Tran so f sec ondary sc irrhous o r fibro -canc

tive tissue o f the lung in a woman, set

of the left m amma fo r the same a

o f acute bronchitis . A m icro secno thing spec ial ; and she died as

Arno tt (ib .,2 3 1) gives a case o f epithelioma o f the heart and

in a woman ,set. 50 , secondary to epithelioma o f the c lito ris .

Sparks Lancet, ’ 187 1 , ii, 13) publishes a sho rt no te o f

m ortem appearances found in a case o f primary cancer o f

The patient, a woman, set. 2 2,was suppo sed to have died

pneum onia . There were no dules o f encephalo id cancer in

m embrane on the right p leura and in the lower lo beThe lower two thirds o f the left lung c onsisted o

phalo id no dules, one of which was as large as a man’ s

extended towards the m iddle o f the body, pushing the heart

the right . It projected also into the left p leura , and had infidiaphragm,

so that nodules projected on its under surface.

was found elsewhere.

Waters (ib . , 2 6) found the right lung the seat o f scirrhin a man . He was said to have been quite well upweeks before death . He was then seized with pain in the

o f the chest and dySpnoea, attended with c ough and

white fro thy sputa . Two weeks later his head,neck,

mities became oedematous . T he mediastinal glandslarged and s c irrhous throughout .Lebert Berl . Klin . 187 1 , gives three

cysts o ccurring in th

who se earliest symptoculo sis . Half a yearfo und some c onso lidat

1870 , b e spat up hyda

caNcna’

l—rnrm sw. 125

he go t better and was still alive when Lebert wro te . In the second

fie,a girl Of 2 3 presented a fluc tuating tumour in the left hypo chon

°

um ,which was supp o sed to be hydatid o f the spleen . In the third

case pneumo thorax o c curred from perfo ration of the echino c o ccus cyststhrough the pleura. During life th is case had als o been lo oked o n as

tuberculo sis . Lebert makes some remarks on the diagno sis and etio logyo f the rare o ccurrence of primary echino co ccus o f the lung . The seatis generally in the lung-tissue.

l n the case reco rded by Zuber (‘Gaz . des 1 872 , 7 o f a

hydatid cysts burst into the pleura and s o

case also the symptoms during life were tho se o f

from the ‘Australian Medical Journal ,’ ‘Lancet,’ 187 1 ,lished a paper on the disease, which seem s to b e m o re

stralia . The m o st c omm on site o f hydatids o f the lunge o rgan . There may b e no symptom s, and when they do

to the author,the rarity o f visible veno us engorgem ent distinguishes

the case from one Of intrathorac ic cancer . One tapping ,fo llowed by

po tassium and kamela,are general ly succes sful .

by any o f these writers upon the origin o f the

chino c o ccus -cysts in the lung they seem to c on

w the fact that it is m o st c ommon in p laces wherethe drinking water is p o lluted by the excreta o f dogs containing the ova

of taenia .—Rep .)

P fitkisz’

s .

Condie On Spurious Consumption,

” Amer. Journ . Med. lxi i,

389) distinguishes a tubercular and a n on -tubercular phthisis, whichmay be very easily c onfounded. In bo th there is the same progres siveand extrem e emaciatio n

,c ough , expectoration

,debility, hectic fever

and night sweats . Their physical signs are also alike. But as regardsprogno sis it is essential to rec ogn ise the difference , and to do s o attention must be paid to the c onstitution

, predispo sition , hereditary tendenc ies

,and sputa Of the patient . In tubercular disease o f the lungs the

sputa, in the early stages at least,c onsist m o st c ommonly o f a white

frothy mucus ; later they become c on s istent and glairy, and o f a darkerhue . They are interm ixed with sm all whitish partic les o f a cheese- likeappearance

—bro ken-down tubercular m atter—and n o t unfrequentlywith distinct m asses o f a well-defined purifo rm character. The non

tubercular affection o c curs somewhat suddenly, in m o st instances afterexpo sure, with acute bronchitis o r pneum on ia .

Moxon Path . So c . xxii,66) finding in the same lung

patches with iron grey centre, but surrounded by zones which differedin character, believes that the case pro ves the identity Of “

grey and

yellow tuberc les . ” He as sum es that these patches grow from withinoutwards ; that the central is the Older po rtion ,

the peripheral the m o strecent . The outer zone Of one patch presented grey .(miliary) tuberc les ;that o f the o ther “ larger, Opaque, yellowish-white tuberc les o f the mo stscrofulO-pneumonic type .

” Bo th kinds “ were seated in the proper


pulmonary tissue, and no t espec ially about the ends o f thtubes . ”Fox (E . L .) Brit. Med.

187 1 , 11, 463) ren ews

assertions, and o ppo ses them generally . He ho lds thm onia

,when it is found ass o c iatedWith

with it as cause and effec t, and that.

in cases in which the patient has prevmusly had the tuberculoOf c onstitution .

Further, he insists that it is no t unusualgenera

l (miliary tubercul o sis without pre-existing cheesyration .

Sommerbrodt Vireh . IV,165) has made experiments

to test N iemeyer’s theory as to the effectphthisis . The blo o d drawn from the caro tidinjected through a wound in them trachea,

the characteristic cells Of catarrhal neumonia in certain portionstissue to which the blo od had foun its way.

KOrner (“ Beitrag zur Lehre von der Tuberculo se, ” Wien .

artific ial,and canno t be supported by anatomical fac ts ,

two results are almo st always found together . In

Niem eyer i s unable to say why cheesy pneum onia leadm ent Of tubercle in one case and no t in ano ther.

Rokitansky ’s views as to the an

fo rward the fo llowing theo ry asthe lung can be preserved onlydevelo ped inspirato ry musc les . The latter are ill -developed in patientsOf the so -called phthis ical habit

,and here the defo rmity is sec ondar

But, on the o ther hand, it may b e acquired, from anaamia, &c . fh

either case the apex o f the lung Obtain s less than no rmal respirato ry power, and bec omes relaxed. Ko rner concludes that thisc o llap se leads to abnormal pulsation in the vessels

,to changes in

the c irculation in the vasa vasorum,and thus to altered nutrition o f

the lung-tissue.

Kennedy (‘Dub l . Quart . J li,106) o ppo ses Niemeyer’s views

on phthisis , supp orting the o ld theory of the patho logy and c ourse Ofthe disease . (It is, perhaps, well that the autho r adm its at the veryc ommencement o f his paper that his “ rem arks have been put togethersomewhathurriedly .

”-Rep .)

Acc ording to the Med -Chir. Rev.

’

(xlvn , 545) Sko da also critic isesthe do ctrines o f NIemeyer. He seem s to think that Observations, bo th


tained results of certain c limates on sim ilar cases . He thenstatistical account o f 2 5 1 o f the ab o ve 10 00 c ases who at one

ano ther were submitted to the influen ce Of warm c lim ates fo rvarying from one to eleven years . He

c limates o f different places , and c onc ludes thattho se who wintered abro ad and tho sewho dld

Condie Amer . Journ . o f Med. lxii , 1Of the c ontagiousness o f phthis is, and givesgive m ore o r less pro bability to thi s theory .

previously healthy man who died of c onsumphis wife had succumbed to the same disease.

T o the question whether it b e proper fo r consumptivesC . J . B .

Williams Brit .Med. 187 1 , i , R . Band H . Bennet (ih .

,agree with Virchow in gm

tive answer.

Tait Dub l . 111, 3 1 7) wishes to su

for the muscular irritability Often seen in patients suffering from chestaffections

,and first no ticed by Graves and S tokes . These writers

described the appearan ce, after percussion, Of a number of little tumo ursexactly corresponding to the number and situation o f the po ints o f thefingers where they had struck the integuments Of the chest . Theyc ontinued visible fo r a few moments and then subsided, but could beagain made to appear by repeating the percussion . Their appearanceseemed to be due to the c on traction o f muscular fibres , in c onsequenceo f the irritation Of the blow (factitious urticaria Of Gul l, 85 0. Rep ) .

Tait gives sho rt n o tes o f 1 1 7 c ases in which he no ticed the phenomenon ,

and a table Of 90 o ther Observations in which it was present . Only 2 6

Of his 1 1 7 cases died, and he finds one c omfo rt in the fac t “ that themajo rity o f prac titioners have n o very ac curate no tion Of how manyc ases Of consumption there are which rec o ver—get well as abso lutely asdo cases o f measles . (The writer gives no physical signs in the

maj ority Of the cases,and hints only slightly at the p o st-m o rtem appear

ances in two cases (53 and The who le paper is m o st careless anddogmatic .

—Rep .)

Ludwig, “ Im Ob erengadin entstandene to dtlich verlaufene Phth isis ,” ‘Areh . d .

xii, 494 . Hirsch , Beitrag zur Casuistik dcr galoppireudeu Lungenschwindsucht (kasige Berl . Klin . Wo ch 187 1 , 198. Pilz , E in Fall vouchro n ischer Pneum onie m it Geh irntub erculo se und E ktas ie der Speis ero hre,” Jahrb .

f. iv, 433 . V an der Co rput,“ No uveau m ode de Tra itement de la.

Phth isie nu m oyen de l’

huile de Fo ie dc Mo rue saponifi ée par la Chaux, ” Bul l. Gén .

de 80 , 205 . Perroud, De quelques Phénoménes nerveux survenant dans lec o urs de la Phth is ic Pulm onaire,” ‘Lyon ix, 6 . Mayet,

“ Inflammation desFo llicules c lo s de l ’Intestin dans la Phth is ic ,’ ih ., 33 . Boudant, De la Phth is ic aux

eaux de Mont-Dore,”ib ., vii, 439. Tyson, C irrho s is and c omplete Atro phy o f the

Left Lung, Cheesy Depo s it w ith M i liary Tuberc le thro ughout the Right Lung ”

(man , eat .

‘Am er. Journ . Med . lxi, 163 . Id ., ( 1) Phth is is , Cavity at Apexo f each Lung , dissem inated Miliary Tub erc le and Cheesy Depo s it ” (boy, wt. 19) (2)“ Phth is is, Cavities , Cheesy Dep o s it o nly ”

(girl, wt. ih . , 4 2 9 . Hutch inso n ,

Phth isis diagno sticated by aid Of the M icro s co p ic E xam ination o f the Sputa (boy,set. 19, w ith autop sy) , ih ., 1 53 . Co ndie, Tub ercular Pneum onia , ih . , 365 . Id .,

Hacm optysis in Co nsumptive Patients ,” ih ., lxiii , 97. Id., On Hectic Fever, ib .,

PHTHIS IS—CARDIAC MURMURS, E TC . 129

ih ., 365 . S im ons ,“ Clim ate and Its relations to the Production , Pro gress, Am eliora

tio n , and Cure o f Co nsumption , ih . , ih . , 82 . Bennet (J . O n the Treatment o fPulmonary Con sumption by Hygiene, Clim ate, and Medic ine , in its c o nnec tion w ithModern Do c trines , ” London , 187 1 . Mo xo n,

“ On the Varieties Of Tub erc le, and therelation o f Tub erc le to Inflammatio n ,

” Med. Tim es and 187 1 , i , 64 . Hartsen ,

N O well-known Sym ptom s Of Phthi sis Rem arks o n th eir E xplanatio n , ib .,i i, 586.

All butt,“ Ph th is is as a Neuro s is, ih . , ih ., 613 . Rus sell , “ Acute Pulm onary Con

sumptio n , ih . , ih ., 5 2 6. W illiam s Case o f Co ntra ctile Phth is is caus ingremarkab le Disp lacem ent Of Organs, ih . , ih . , 73 2 . Ogle , “ T he Ac tio n o f Sulphateo f Quin ine up on the Temperature in Pulm onary Phth is is ” (no prop o rtionate m odifi

cations Of resp iratio n, pulse o r heart b eat, ac c ompan ied the fluc tuation s) , ‘Lan c et, ’9 . Ph ilip son ,

“ Repo rt Of a Case of Phthis is Pulm onal is, ac c om pan ied byU lceration o f the Larynx and Plastic E xudatio n into the Trac hea and Bro nch i(man , set. ih . , i , 85 5 . Bradbury , No tes Of a Ca se o f Phth is is ab HaemOpto e (P) ,with Rem arks, ” ih . , 187 1 , ii , 60 2 . Bro ster, On the Treatment o f Phth is is Pulmoh alis by Glyc erine and Indian Hem p, ” ih. , i , 4 7 . Pea co ck , Clin ica l Lecture on

Haemo ptys is , ” ih., 11, 875 . Bradb ury, “ Case o f a rare fo rm o f Pulm onary Haem o r

rhage , w ith b rief Rem arks , ” Brit. Med . 187 1 , i , 35 . Id . , On the

Progno stic Value o f Haem o ptys is , ” ih i i , 2 59. W aters ,“ Clinic a l Rem arks o n th e

Treatment o f Hmm op tysis ,” ih . , i , 2 47 . Jam ieso n , Sub cutaneo us Injec tion o f E rgo

tine in Haem optys is, ih ., E am es,Haem optys is in advanc ed Ph th is is , ” ih . , i, 433 .

Co tton , N o tes o n Co nsumption ,

”ih . , i, 19 2 . Law ,

“ Lungs and Larynx o f a m an ,

act. 44 , wh o died w ith Phth is is Laryngea , ” ih . , 342 . Green, Aneurism o f a Brancho f the Pulmo nary Artery in a Phth i s ical Lung.

”Path . S o c . xxn , 3 7. Powell,

Some Cases i llustrating th e Patho logy Of Fatal Hsem o ptysis in advanced Phth is is, ”ih . , 4 1 . Squire, Part o f th e Upper Lob e of Left Lung , wh ere two years ago s ignso f Tuberculo s is had b een a rres ted by Quin ine ; also E nlarged Kidneys and U lceratedIleum , w ith large Mesenteric Glands from the sam e ch ild, ” ih . , xxiii , 35 . Greenh ow ,

Lungs from a Case O f Cured Phth is is Death from Cap illary Bronch itis ; Cavitieslined w ith False Memb rane in bo th Lungs , Pro liferatio n Of Interlobular Co nnectiveTissue and great Th icken ing o f the Pleura ,” ih . , ih .

, 49. Gue’

neau de Mussy,Observations de Ph th is ic latente, ” Gaz . vm , 2 96. Perroud, Influence de

laVario le sur la Ph thisie la tente, " Lyon vii i, 3 7 1 . (And see under

D .

- Dis ea ses of the Circulato ry System .

Origin of Cardia c M urmurs, &c .

Jac obson Ueber Herzgerausche,” ‘Berl . Klin. 187 1 , 588)

remarks that even experien ced auscultato rs find a difficulty in ascer

taining the prec ise c o inc idence o f a murmur with a c ertain perIOd o f

the heart’ s action . The usual attention to the pulsatio n Of the

caro tid,o r to the heart’ s impulse, is hardly prec ise eno ugh in the

absence o f a s imultaneous pro o f o btained by hearing and feeling. T o

remedy this defec t he has invented an instrument, thro ugh which the

mo vements o f the artery are transmitted by a lever to an elec tro -magnetic c lo ckwork . The m o tion o f the latter gives an audible s ignal,which may thus be c ompared with the no rmal o r abno rmal so unds Ofthe heart . The use Of this instrument is said to be as ea sy as that o fthe ordinary sphygmograph .

G iese (“ Versuche iiber die E ntstehung der Herzto ne,‘Deut .

187 1 , 393) has repeated and c onfirm s the experim ents o f Bayeron the m o de Of o rigin o f the first sound o f the heart . He made use o f

fresh calves ’ hearts, in which he remo ved the left auric le s o as to

expo se the m itral valve, and also cut away the aortic valves . Into the9


a o rta he introduc ed a tube ten feet long, with a s to pco ck . On Open ingthe latter water poured into the ventric le and c lo sed the m itral valves .

The stop co ck was s o c onstruc ted (see the o riginal paper) that afterthe valve had c lo sed it Opened again o f itself. Aus cultatio n was made

with a stetho sc o pe dipped in the water, b ut no t res ting immediate ly o n

the heart . In this way a weak and dull so und was heard o n the c lo sureOf the valve, beginning, but no t ending, sharply, and in no way whateverlike the first sound heard in the living bo dy . In in suffic iency o f thevalve the so und was no t heard. In ano ther series o f experiments on

the sem ilunar valves a c lear c lapp ing so und was o btained , exac tly likethat o f the second so und o f the living heart . The c o nc lus ion he drawsis

,that the c lo sure Of the m itral va lves (during life) do es appear to

produce a sound, but that this sound is no t that Of the full firs t so undo f the heart, and that the c om ing together Of the valve plays only asec ondary part in the pro duction o f the real firs t s ound.

Po ore Lancet,

’

1872 , 11,1 18) intensifies the cardiac s o unds by

plac ing the patient on his back o n a wo o den bench , applying the end Of

a stick between the third c o stal cartilages, and balancing the soundingb ox o f a guitar, with its aperture towards the tho rax o f the patient o nthe o ther end Of the s tick .

Hyde Salter Lancet , ’ 187 1 , 11, 15 1) cal ls attentio n to the existence'Of auricular pericardial frictio n, and gives fo ur c as es , in three o f which,a man

,act. 2 1

, and two women O f m iddl e age , a frictio n - so und was

audible at the inner extrem ity Of the third right interc o stal s pace ; in a

fourth case, in a woman set . 2 9 , the same murmur, resembling a pre

systo lic one, was limited to a po int o n the third left rib,about an inch

to the left Of the margin o f the sternum . T he auto psies Of two , who sedeath was due to uraemic pericarditis , are given,

in proo f Of the c o rrec t

diagno s is . In o ne the left auricle was c o vered and ro ughened withlymph , which was c onfined to the surface Of the auric le ; in the o ther,the s ound extended down o ver the ventric les and became general , asdid the pericarditis . Attentio n is strongly drawn to the presysto lic character o f the so und. In the firs t c as e (ih . ,

2 5 1) Salter no ticed a

c urio us phenomeno n z— One m o rn ing the pul se beats and respirations

were exactly equal , 58 next day there were two bea ts to one respiration,

and the day fo llowing the ulse beats , without any c o nnexio nwith the respiration , came regularly in c o uples .

”The fo rmer pecu

liarity he had no ticed in a few o ther cases,one o f which he gives ;

and he thinks that the explanation o f what he terms sphygm o

pneumal synchronism ”is to be found in an acc omm o dation Of the

resp iratory m o vements , perhaps witho ut any co n sc io usness on the partOf the patient , to the mo vements Of the heart . In bo th cases rec o rdedthere was pro bably adherent pericardium ,

o r adherence between it andthe lung . He gives two further cases, to illustrate the o c currence o fc o uple-rhythm .

”

G uéneau de Mus sy (‘Gaz . des 187 1 , 133) gives a c linica llecture on a case o f ao rtic insuffic iency . Here the dias to lic murmur

became gradually feebler, while a loud systo lic murmur was develo ped .

He c onc luded that the abno rmal aperture Of the valve was graduallybeing lessened and c lo sed by vegetations , and a gradual steno sis taking


tion o f the heart in a number o f bein enlargement o f the left ventric le the heartand in that o f the right ventric le is in creased in breadttrue .

The‘Lancet’ (1872 , i , 149) contains an abstrac t o f

Duchek , in which he discusses the o rigin Of the bruit da

murmur is m odified by the strength o f the pul se in

(m oments Of reinfo rcement) and by ac celeration o f the

ho lds that it is due to the vibratio n o f the half-Openbulbus o f the jugular vein behind the insertio nand requires for its production a rapidnorm al pressure Of the blo o d in the tho rax . If the latter isby valvular failures, emphysema

, &c .

,the murmur is n o t b

hence the general view that this murmur exc ludes insuffic ienm itral .Allbutt St. Geo rge

’

s Ho sp . v , 2 2 ) writes on the effec ts ofo verwork and strain o n the heart and great blo o d-ves sels . He gives thefo llowing as the o rder in which the chro nic mo rbidpresent themselves fo r c onsideratio n Dilatation(2 ) dilatation o f the left heart, (3) in reason ,

if no t in

o f the left ventric le, o r bo th ventric les , (4) chronic inao rta and aortic valves, 5) dilatation o f the ao rta

,

Of the aortic valves,left ventric le, (8) 10

among o thers,may and Oftenmeets with simwho have beenunhes itatingly, as the beginni

into the fac ts which bear upo ngraphic trac ings Of differenttempted to attribute phthis isleast remarkable that many o f tho se suffering from

phthisis seem to have enjoyed go o d hea lth up to the times ome cause o r o ther haem optysis o c curred (c f. Med. T imes187 1 , i,Stone New Y o rk Med. vi

, 36) feels quite c erta in tpro portion Of diseases Of the heart may be warded Off o r verygated. A large propo rtionwhich o c curs m o stly in thesuppo sed begin purely as

relieved, lead on to dilatatc onsequences o f Obstructed c irculation thro ugh the o rgan .

s tress upon no t waiting for a friction sound o r murmur, fo r inthe rheumatism o f children, but exhibiting drugs at o nce . Hison functional derangement c ontain no thing new .

Snelling (ih .

,6) gives sho rt no tes o f twenty ca ses in wh ich

elavIan bellows -murmur was heard. He gives a table in which

ORIGIN OF CARDIAC MURMURs,E TC . 133

are analysed, and c o nc ludes that in certain cases , when the depo sitionOf tuberc le is to o slight to give rise to phys ical signs the murm ur

,

taken in c onnectio n with emac iatio n and c ough, may b e lo oked upon

alm o st as patho gnomon ic ” Of phthis is .G ray Brit. Med. 187 1 , 11, 94) refers sho rtly to three cases

o c curring in his own prac tice , Of phthisis, s trumous diarrhoea , and bro nchitis aftermeasles , in which death from c oma was preceded by a fall inthe frequency Of the pulse .

Brunton St. Barth . Ho sp . vn,2 16) has made several experi

ments o n the effec t o f temperature o n the rabbit ’ s heart while it s tillremained in the b ody

,s ometimes leaving all its nervous c onnections

unto uched, and s ometimes dividing the vagi . These experiments weremade by narc o tising the animal with Op ium o r chlo ral

,and laying it in a

tin ves sel well padded with c o tton wo o l . T he ves sel was do uble, and bypouring ho t water into it, the temperature o f the rabbit was graduallyraised. T he belly o f the animal was also c o vered with c o tton wo o l ,sometimes with an india-rubber bag c ontaining ho t water. T O make

respiration easier, a canula was introduced into the trachea, and the

inspired air pas sed o ver warm water. T he pulsations Of the heart werec ounted by pushing a fine needl e through the tho rac ic walls into theheart

,s o that it vibrated with each pul sation ,

and c onnec ting its o uterend by means o f a fine thread with the lever o f one Of Marcy

’

s cardiographs . By this means it is po ss ible to c o unt the pulsations , even whenthe heart is heating at the rate o f 470 in a m inute, as it did in one case .

The temperature was taken with a thermometer in the rectum . He

gives a table, from which it is seen that the heart beats m o re quicklyas the temperature rises till it reaches its maximum

,and then becomes

s lower, and finally sto ps . The increase in the number o f beats is no t

the same fo r each degree o f rise in the temperature, and the numbero f beats at the same temperature, and als o the same am ount Of quickening fo r each degree o f rise o f temperature , differs in differentan imals . The upper limit at which the heat s tands still varies indifferent an imals

, but in the s tro nger o nes it is between 1 13°and 1 14

°

F .

,o r even abo ve it . In some o f the experiments the p ower Of the

vagus was tested from time to time by irritation with an induced cur

rent,and from its pers istent power the writer c o nc ludes that in the

rabbit, and pro bably o ther mamm als ’ hearts,8. temperature s uffi

ciently high to pro duce s to ppage o f the heart do es no t paralyse thevagus o r the inhibito ry apparatus through which it acts . He isinc lined to reject Weikart

’s hyp o thesis , that death from heat is due to

c o agulation o f blo o d in the ves sels, and to agree with Bernard in

fi

lpding its cause in impairment o f the mus cular p ower o f the heart by

t e heat .

Habersh on Lancet , ’ 187 1 , i , 333) writes on the relief o f n o c turna ldyspnoea aris ing from disease o f the heart , and groups it into threec lasses . In the first c lass are c ases Of failing power Of the heart ’saction from lo ss Of blo od and from sudden sho cks to the nervous sy stem . In these cases the ac tio n i s feeble and o ften irregular, and the

best treatment c ons ists in the adm inistration Of n ourishment , the properuse o f stimulants

,and afterwards the emp loyment o f steel , with nar


co ties if sleeplessness o r pain b e present . In a sec ond ela

disease c ons ists in imperfection Of the mitral valve, andresults ; here the treatment is to b e directed to the Inn

kidneys ; narc o tics have only a trans ient benefit, o ften

increa sed distres s . In a

muscular p ower Of the heatheroma Of the ves sels, iand dilatation . Here stimulating narc

chlo ro fo rm ,campho r, senega , amm o nia and Indian hemp .

c ontains suggestions as to the general dietary regul a tio ns.

to

lowed, and c on cludes with the writer’s experience o f vari ousemployed by himself.Hering, “ Ueb er den E influss der Athmung auf den Kreis lauf , ” W ien .Med .

1872 , 3 7. Ko lisko ,“ Beitrag e zur Kenntniss der Mechan ik des Herzens ,’

Beneke, “ Ueber die Lum ina der

c onsequent on Syph ilitic Cachexia (gumm ata in heart), Dub lin Quart. Jo urn . ,

Unilateral Anesthes ia without impairment of Mo to r Po

the sub jec t Of Heart Disease, ” ih . . 246 . Lac cas sagne,“ Des Complicatio ns

diaques dans la Blenno rrhagie, ” ‘Arch . Gén . , 1872 , i, 15 . B . W . Fo ster, Digiand Heart Disease, ” Med.

-Ch ir. xlvu i, 2 14 .

E mbo lism,Thrombo s is

, &c .

Wrany Oesterr. Jahrb . f. Paediatrik,

’

187 2 , 1 2 gives the ca se Of

b oy, set . 9 ,in whom endo carditis was fo llowed b emiplegia, aph

and hem icho rea . The auto psy showed fattyheart, disease o f the m itra l valve

,adhere

m onia o f the right upper lobe, oedem a o f

m iddle cerebral artery , with c onsequenttum and lenticular nuc leus ; infarc tahaemo rrhagic ero sions in the stomach ,testines .

Murchison Trans . Path . xxu,1 19) reco rds the case o f a girl ,

ast . 14, who had fo r years suffered from cho rea, with m itral defic iency .

136 RE PORT ON P RACTICAL ME DICINE .

evidence gained elsewhere, the autho r c o nc ludes that the o rigina l causemust have been embo lism . T he sec o nd case was that o f a man

, wt. 63 ,

wh o had been much addic ted to drink . On the evening befo re hisadm iss ion into ho sp ital he was suddenly attacked with vom iting and

inability to swallow. On his admis sion there was general muscularweaknes s , but c omplete intelligence and liveliness . There was c ompletelo s s o f power to swallow,

tho ugh the velum c o ntrac ted well . There wastrem or

,but no paralys is Of the upper extrem ities , slight by ermsthesia

Of the lower ; he to ttered if he attempted to stand, an showed a

tendency to fall towards the left s ide . Next day he died. T he valveso f the heart were fo und thickened and atheromato us , as a lso the arteries at the base o f the brain . One c entimetre from its o pening into thebas ilar the left vertebral artery was co r

lpjpletely Obstruc ted by deco

lo urised,yellowish c lo t. N o traces o f i aretus were fo und in any o f

the abdom inal o rgans . Charco t remarks o n the cases , that the

symptom s o bserved were extremely s imilar to tho se seen in labio -

glo ssopharyngeal paralys is .

King, “ A Ca se o f Aortic andMitra l Valvular Disease, w ith E xtens ive Infarction Of

the Sp leen and Cerebral So ften ing ”

(m an, wt .

‘Path . So c . xxi ii , 63 . Id. ,

“ Aneurism o f the Ao rta as so c iated w ith Fra cture o f the Firs t Rib , and Embo lismo f Left Middle Cerebral Artery (m an, we. ih . , 70 . Mo lliere, “ De l

'

Embo lie

des Arteres Mésenteriques , e'

tudes critiques et b ib lio graph iques , ” Lyon. vi ii ,69 1 . Ram skill, “ Thrombo s is o f Right Iliac Vein, Embo lism o f Pulm onary Artery ,

Sudden Death (m an , set.

‘Med . Tim es and 187 1 , i , 660 . Merkel, CheyneS tokes ’schen Respiratio n stypus m it Pendel-b ewegungen der Augapfel. Rheum atischeEndo carditis ; E nceph al itis in Fo lge von E mbo lie der Arteria fos saa Sylvn dextra

”

(g irl, set. Deut. x, 2 0 1 . Schm id, Zur Differentialdiagno se vo uApo plexieund Embo lie des Geh irn s , ” ih . , 305 . Cohnheim ,

“ Unt ersuchungen fiber die Em

b o lischen Pro cesse, Berlin, 1872 , pp . 1 1 2 (reviewed, ih .,

P ericarditis .

Wilks Guy ’s Ho sp. xvi,

196) writes o n adherent pericardium as a cause Of cardiac disease , and discusses the different viewsheld by Ho pe, Co rvisart, Barlow, Chevers , &c . He ho lds it probablethat lo o se cellul ar adhesions have no apprec iable influence on the

action o f the heart, but that the thickened pericardium o f a cartilaginous c on s istency, investing the heart c lo sely, arising from an inflammation at an early period o f childho od

,do es lead to Obstruc tio n o f the

c irculation ,and then to dropsy, after the manner Of heart disease . T he

c ondition Of adherent pericardium canno t be regarded as a rare o ne .

He gives six cases in which death was apparently due to this affec tio n ,

and is almo s t inc lined to o ffer the pro po s ition ,that in a well-marked

case o f disease with c ardiac symptom s in young pers o ns without anyvalvular bruit pericardial adhesions may be fairly expec ted. In Olderpers ons, Of c o urse, we should lo ok rather to degeneration Of musculartissue . Of the c ases rec o rded in this paper, five were males

,aged re

Spectively 2 1, 9 , 1 2 , 2 6, and 2 4 ; the o ther is that Of a girl, aged 16 . The

symptom s comm on to all were dyspnma, cyano s is , drop sy ; in none was

any bruit heard ; in al l the pericardium was universally and c lo selyadherent . (T he first case has been rec o rded alreadv by Barlow

,

‘G uy ’ s

Ho sp . ser . 3 , xi, 437 .—Rep .)

PERICARDITIS—MY OCARDITIS, E TC . 37

G lo ver Lancet , ’ i , 893) rec o rds the c ase o f a girl, set. 1 2 , who hadcomplained o f pain in her left side fo r two o r three weeks . Her tem

perature seven days befo re death was N0 phys ical signs seemto have been made o ut . The auto psy showed the pericardiumdistended with pus , and purulent lymph adhering to its innersurface .

Frémy,“ Peric ardite . Epan chem ent de Séro s ité purulente. Ponctio n avec l ’Appareil

du Dr. Dieulafoy, Guérison ”

(man , set. ‘Bull . Géu . de t. 8 1, p . 1 2 5 .

Thiriar,“ Pericardite, avec E panchement c ons iderab le et b rides adh és ives , suite

d’Affec tions Rhum atismales ”

(bo y, set. 16, auto psy),‘Presse Méd . Belge, ’ 187 1 , 3 2 .

Heaton ,

“ Rheum atic Pericarditis w ith Efius io n, Recovery (m an , eat.

‘Brit.Med. J 187 1, u , 96. Thorowgo od, Pericarditis w ith E ffus io n , Death

”

(b oy,set. 10 , autop sy),

‘Lancet, ’ 1872 , i , 682 .

D iseases of Myo cardium Heart Aneurism, &e.

Quain Lancet,

’1872 , i, 39 1 ) thinks that affec tions o f the walls o f

the heart have been s omewhat neglected in the attention paid to

valvular affec tions . He ho lds that c linical study o f the fo rmer teachesthat the really serious effects o f heart disease resul t from hypertrophy, o r from dilatation

,o r from . a c ombination o f the two ; (2 )

valvular diseases may exist up to the c lo se o f a long life witho ut rendering the subjec t o f them c o ns c ious o f their presence ; (3 ) it is p o s sibleto refer to cases in which , valve disease having existed without caus ingany inconvenience, som ething o c curs which damages the c ondition o f

the muscularwalls,and serious disturban ce is the result (4) there are

cases in which s ome additiona l m ischief o ccurs to valve disease alreadyexisting, and this m ischief is rem edied by the supervention o f furtherc ompensato ry hypertrophy ; (5) the c onverse o f the las t c lass is seen incases o f valve disease in which the heart walls fail and the disease progres ses ; 6) c ases o c cur in which valvul ar disease—i. e. incompetencyis caused by dilatation o f the heart. E nlargement o f this o rgan maydepend

—(a) on an increase in the mus cular fibres , the exac t changebeing still unknown (b) on an increase in the c onnec tive tissue, due tochronic interstitial inflammation o r hyperplasia ; (e) on an in crease o f

fat,no t to be c onfo unded with fatty degeneration . The causes o f

enlargement o f the heart may be c lassified as—agenc ies ac ting thro ughthe nervous system

,as o vers trained exc itement agenc ies ac ting mecha

nical ly, as severe and repeated muscular exertion, o bstruc ted c irenlation ,

pregnancy ; agenc ies o riginating in disordered c onditions o f thenutritive func tions o f the heart, as chloro s is , anaem ia , go od living within suffic ient exerc ise, Bright ’s disease, adherent pericardium . The

autho r pro ceeds to dis cus s (ib . , 4 2 6) the system ic effec ts o f enlargement, and the relation o f heart disease to ph this is and renal disease, andthe s eco nd lec ture c onc ludes with the diagno s is and treatment o f it .In s imple mus cular hypertro phy, repo se, and the adm inistration o f

ac onite ; in c onn ec tive-tiss ue hypertro phy, if diagn o sed in its earlystage, remedies likely to subdue the inflammatio n in which it o riginates ; and in fatty hypertro phy, treatment calculated to prevent theformation of fat , are rec ommended and to o btain compen sato ry hypertro phy, iron and digitalis . In a third lec ture (ib .

, 459) he enlarges on

138 RE PORT ON PRACT ICAL MEDICINE .

fatty degeneration and rupture (see under

describes aneurism o f the heart , the wall s o fth in and altered cardiac walls , all the layers 0

near the base, b ut in many cases o ver the res t

layer has disappeared. O c cas ionallyTh is affec tion seem s to o c cur Wi th nearly the s ame frequency at

different ages , but always with a marked preponderan ce o f ma les in thecases c o llected. It may o riginate in inflammatio n ,

fatty degeneration , o r the bursting o f an ab sces s . The les io n is m o st frequentlyseated at the apex, and is no t ac c ompanied by any s pec ial sympto ms .

Fo thergill a l so dis cusses Brit . Med. 1872 , i , 2 36) thesubjec t o f hypertro phy and dilatation . As to Its mo de o f o rigin,

as

some name must be used to c o ver what we do no t know, hypertro phym ay be c alled a trophic a c tion o f the c ardiac ganglia , ” by which theheart res ists dilatation . He th inks that in time it m ay be p o s sible todem on strate that it is the c o nsequence o f an increas ed blo o d suppl to

the muscular structure , dilatatio n o f the c o ronary vessels,and sec ondary

elo ngation o f the heart-fibres .

Thompson (“ Distrain o f the Heart,

”St. Geo rge’ s Ho sp . v,

1 19) rec o rds three cases,to show that dilatation o f the heart is n o t

always a chron ic disease, but m ay arise suddenly and from an acc identa lc ause . T wo o f these o ccurred in men , ast . 2 3 and 2 8

,and the o ther

in a girl , act. 19 . T he po st-m o rtem appearances are given in the firs ttwo cases , the last one rec o vered. He has seen seven o f these cas es

altogether, and o f the who le number three made a go o d rec o very,

the c onstitutional disturbances pass ing away, tho ugh the heart remainedpermanently injured.

Sm ith Brit . Med. 187 2 , i , 597) showed to the Patho logicalSo c iety o f Dublin the heart o f a young man , set. 2 2 . He had c aughtc o ld some time befo re hi s admiss ion into ho spital ; oedema o f the feet ,general anasarca

,and cyano s is fo llowed. The area o f praec o rdia l

dulnes s was increased ; there was no murmur,but the first so und o f

the heart was doubled, and ultimately the actio n o f that o rgan becamestrikingly verm icular. The left half o f the to ngue became swo llen,

and

the patient died rather suddenly. T he pericardium c ontained half a

pint o f serum ; there was no recent pericarditis ; the heart was muchdilated

,but its valves were no rmal . T he right auricle was much eu

larged, but no t hypertrophied.

Wagstafl'

e Path . So c . xxu, 1 2 ) reco rds a case o f fibrous

tumour o f the heart . The spec imen had been lying in pickle fo r

fifteen years befo re it came into his hands . T he patient from whom itwas taken was a female child, eat. 3 m onths , which seem s to have diedfrom c onvuls ive fits . At the p o st -m o rtem it w as found that the peric ardium was distended with a quantity o f p inkish serum . The heartwas greatly enlarged, its shape elliptical , the apex nearly a s large as the

base, and o n one side o f this,towards the right ventric le, the mus cul ar

struc ture appeared to be thinned, and presented an a lm o st tendino usappearance . The cavities o f bo th auric le and ventric le were dim in ished by the projection into them o f the septum , in which c o uld befelt a tough inelastic mass . On cutting down upon this it was fo und


c ardiac wall , in a child set . 4 years, who died from pyaem ia . He al s o

adds a table o f fo rty-two cases o f the latter disease, to be found in thePath . So c . Tran s . ’Co ats (‘G lasgow Med. Iv, 433) reco rds two cases o f cal

careous infiltration Of the m uscular fibre o f the heart . In the first casethe sa lts o f lime, probably c ompo sed entirely Of the pho sphates , hadbeen depo sited in the fibre in the fo rm o f m inute ro und granules ,giving the appearance bo th to the naked eye and under the m icro sc o pe

o f fatty degeneration . The patient, a man who died o f fever, presentedsigns o f chronic bronchitis and emphysema

, with probably some syphi

litic ta int . In the sec ond c ase, o ne o f relapsing fever and pyaem ia, themuscular fibres were c onverted into cylinders having a c onsiderablycrystalline texture . The lime salt was dep o sited in a m inutely granularfo rm ,

and c onsisted in great part o f carbonate o f lime, which effervesc edon the addition o f hydro chlo ric ac id.

E ndo carditis .

Peaco ck (“ On the Progn o sis in cases o f Valvular Disease o f the

Heart,” St. Thom . Ho sp . 187 1 , 2 33) regards in co mpetency o f

the val ves as a more serious defec t than Ob struc tio n,and in competency

o f the aortic mo re dangerous than that o f the m itral valves . On the

o ther hand, o bstruction o f the m itral is apparently a mo re impo rtantdefect than c on stric tion o f the ao rtic valves . He reviews the generalquestions o f diagno sis and treatment at some length .

Fagge (“ On the Murmurs attendant upon Mitral Contraction,

Guy’ s Ho sp . xvi,2 47) writes with spec ial reference to the re

systo lic murmur. T he paper c o ntains his to ries,m o re o r les s full

)

,o f

sixty-six patients , arranged in three groups ; seven in which the murmur was heard during life and m itral c o ntrac tio n fo und after death ,fo rty cases in which the latter c onditio n was fo und without any pre

systo lic murmur being heard, aud n ineteen in which the murm ur was

heard but no autopsy made . He gives also two cases in which a

peculiar murmur was audible,and in which he diagn o sed m itra l

c ontraction .

Heiberg Vireh . lvi , 40 7) refers to a case o f ulcera tive endo

carditis published by Winge , and des cribed by him as myco s isendo cardii.

”The patient

, a man set. 44 , had had an ulcer o n one o f

his to es, pain s in his j o ints and rigo rs . The auto psy,which Heiberg

gives , showed vegetations on the va lves o f the heart, and the micro s c operevealed the presence o f numerous fungi in the vegetation s , and al so in

the embo li found in the renal and o ther arteries . Winge referred

their pro bable o rigin to the ulcer on the to e. Heiberg rec o rds a case

Of the sam e kind o c curring in his o wn p rac tice , in a pregnant woman ,

set. 2 2 . During life she had rigo rs and pa ins resembling rheumaticpain s . She had als o so res on the sacrum . After death

,in addition to

these gangrenous ulcers , the autop sy showed ulcerative endo carditis o fthe m itral valve , with thrombi c ontaining fungi ; infarc ta o f the spleenand kidneys , with metastatic ab sces ses in the latter. He lo o ks upo nthe fungus as Lepto thrix ; butVirchow,

in a no te to the paper,tho ugh

ENDOCARDITIS . 141

ac cepting the main f ac ts , do es n o t agree with this view . Ino culatio nexperiments were m ade from b o th ca ses

,but with o ut any results .

Muller Deut . 1872 , 1 ) des cribes the c ase o f a womandying from m itral in suffic iency, in whom after c omplete ces sation eveno f the s lightest respirato ry m o vement the heart-s ounds and the puls ein the caro tids c ould b e distinguished after the lap se o f seven m inutes .

Pulsation was perc eptible in the jugular vein s fo urteen m inutes afterthe last sign o f breathing. In addition to the m itral m ischief

, theautop sy revealed tubercular m eningitis o f the base Of the brain .

Sim on (‘Berl . Klin . 187 1 , 437) gives the case o f a b oy, set.

16,who suffered five weeks befo re death with dyspnoea, alpitatio n ,

rigo rs, c onvuls ions , and lo s s o f c on s c iousnes s . The area o f cart ’s dulness was increa sed, the heart-sounds muffled, but unacc ompan ied by amurmur. Sho rtly befo re death there was an eruption Of petechiae. Atthe autopsy were found the fo l lowing z—Numerous extravasation s o nthe pia mater ; numero us p o ints o f red so ften ing in the brain, m o stmarked in the left tempo ral lobe ; several arteries c o rresponding to

these places were found blo cked with embo li . There was serO -fibrinous

inflamm ation Of the pericardium ,which exhibited numerous ec chym o ses

and m iliary tuberc les . On Opening the left ventric le was fo und an

aneurism o f the m itral valve, ” which is described in full in the text .There were numero us ec chym o ses on the pleura, and several embo licinfarcta in the myo cardium

,bo th kidneys , mesentery, &c .

Whipham Trans . Path . xxii, I 1 7) gives an interesting case Of

diseased tricuspid valve in a man ,set. 55 . Its free edge, as well as the

cho rdae tendineae,were ragged and ero ded from ulcerative pro cesses .

The valve was thick , Opaque, o f a dull red c o lo ur,c ontrasting stro ngly

with the transparent and glis tening appearance o f the m itral . T he

o ther po st-m ortem appearanc es were pleurisy and haem o tho rax ; disintegration o f the right lung ; c irrho s is o f the liver ; c o arse and c on

gested kidneys . In the absence Of any o rigin fo r blo o d-po isoning, thewriter thinks that pyaem ia was the c ause o f ulc eration o f the valve and

o f the pneum on ia .

Peter L’

Union xn,662 ) gives a very full lecture on ao rtic

insuffic iency . After'

giving the physical signs o f the affection,he insists

that it is generally a di sease o f the aorta,and no t o f the heart. The

pain behind the sternum , the angina pec to ris , and the sudden death,

which Often a c c ompany it, po int to the disease o f the vessel , no t to theinc ompetent valves . He divides c ases o f ao rtic insufliciency into twoc lasses

,tho se with and tho se without diseased ao rta, the latter being

by far the m o st comm on . T he disease c on sists in the“

atheromatousdegeneration and the inflammation o f the c o ats o f the vessel

,with their

consequen ces . O ld age , abuse Of drink,and gout, are the chief o rigi

nating causes . The o ther fo rm o f ao rt ic insufliciency is caused byaffec tion s such as rheumatism ,

&c . The rOle which the aorta p lays canbe easily rec ognised by the pain and angina caused by the partic ipationin the m ischief o f the cardiac plexus, by the hard radial pulse, and thearena senilis

,and espec ially if there have been antecedent gout o r chronic

alc oho lism . After remarking o n the sudden death which frequentlyo ccurs in the afl

'

ection, and the shares taken in the mechanism Of it by

142 REPORT ON PRACTICAL M EDICINE .

the disease o f the ao rta and the c ardiac plexus , he speaks Of the mo rb idseries fo rmed by angina , ao rtitis , and aortic i

o

usuffiCIency, and In con

elusion he ho lds that the hypertro phy wh ich generally fo llows In

sufficiency is no t to b e lo o ked o n as a c o mpensato ry and helpful process ,b ut as a c omplication o f the wo rst km d, aggravating the patient’ sc ondition .

Riegel Deut . viii,1 2 9) in a case des cribed

.

by h im,recog

nised the symptom to which Duro ziez first drew attentio n as found In

ao rtic insufficiency—a double s o und in the fem o ral artery . In this casea double so und, no t a blowing m urmur, was audible In bo th femo ra larteries . W ith Traube he thinks it is charac teristic Of a very advancedstage o f insuffic iency ; at

'

the same time an elas tic state Of the arteria lwalls , and great hypertro phy o f the left ventric le , are neces sary re

quisites fo r the pro duction Of the symptom in questio n . Co nsequently,it is better heard in young

peo ple with healthy vessels and truehypertrophy o f the left ventric e , while It disappears , o r is diminished,

in extensive atheroma o f the artery and fatty degeneratio n o f the

heart .Paul Union x11, 7 16) writes a very lo ng paper o n steno s i s

o f the pulmonary artery after birth, its sympto m s and c omplications ,and the pulm onary phthis is which frequentl suc ceeds it . The paperis based on twenty-seven Ob servation s . e discus ses the m odes inwhich it m ay o ccur

,the almo st c o nstant sec o ndary hypertro ph

yr Of the

right ventricle, the ins uflic iency as well as steno s is o f the pu m onaryvalves , and the affectio n s o f o ther valves o f the heart which maya c company it . Its characteristic symptom is a sys to lic

,m ore o r

less rasping murmur,heard o ver the o rigin o f the pulm onary artery, and

in its direc tion . Cyano sis is no t a c onsequence o f this s teno s is .

Pepper,“ U lcerative E ndocarditis, Embo lism of Kidneys (m an, ast. 30 , no

autop sy),‘Amer. Journ . Med . lxi, 43 1 . Padova , Endocard ite Aterom ato sa ,

insufficienza e steno s i della m itra le ; essudato pleuric o rec idivante access i d’asm—aa c c om pagnati da furo r uterino in do nua di 68 anni , ” Gaz . Méd . 187 2 , 19 7 .

Balfour, Clinical Lec tures o n Diseases Of the Heart, ( 1) On the Murm urs and o ther

phys ic al s igns distinc tive o f M itra l Steno s is ," E din . xvii , 43 1 . Beveridge ,Case o f Direct M itra l o r Presysto lic Murmur (g irl, act. 1 7 , auto psy), Brit. Med .

187 1, ii,’

353 . Habersho n, Heart Disease (two ca ses—1, man, act. 30 , w ithaortic insuffic iency, &c . ; 2 , b oy, act. 1 1 , w ith m itral o b struc tion and insuffi c iency,embo lism ), ih ., 7 10 . Hayden , Cardiac Hypertro phy, Pericarditis , Mitral and Tric usp id Constric tion and Inadequacy, Ao rtic Ob struc tio n an d Reflux (man , set. 2

ih ., i, 9 1 . S ieveking,

“ Case o f Hypertro phy o f the Heart, w ith Do ub le Tricusp id (P)Murmur, ih ., 62 . Al lb utt, Tricusp id Regurgitatio n (man , act. 5 5 , autopsy), ih . ,

63. Fitzgerald, “ Vis ib le Pulsatio n o f the Arter ia Central is Ret inae in a Case of

Incomp etency o f the Aortic Valves , ” ih . , i i , 72 3 . Johnso n ,A Lec ture o n Disease

o f th e Va lves o f the Heart,”ih . , 1872 , i, 34 . Duckwo rth , “ Case o f Heart Dise ase

w ith Loud Mus ical Murmur, wh ich passed away,”ih . , 187 1 , i i , 667. G ray, Eudo

and Peri -c arditis w ith out Affec tio n o f the Jo ints, fo ll ow ing Sub acute Rheum at ism ,

after a five weeks ’ interval o f Ob scure feb rile sym ptom s ,” ‘Med. Times '

and187 1 , i, 4 1 . Po well, Cas e of Mitral Ob struct ive Disease (funnel m itra l) term inatingfatally , w ith c erebra l c ompl ic atio n ; w ith rem arks o n this fo rm o f heart diseas e , ”ih . , 395 . Salter, “ Doub le Aortic Murmur, Bulging o f Axilla from Hypertropho usE lo ngatio n o f Heart, Ab sence O f Regurg itant Pulse ,

”&c . , ih . , 539 . Loo m is ,

“ Interesting Cases of Cardiac Diseases , ” ‘New Y o rk Med. vi, 3 28. Spa rks ,

Disease o f Tricusp id and Pulmonary Artery Va lves, w ithout Affec tio n o f the Left


flabby muscular tis sue ; in m o

abno rmal amo unt Of fat, and the fibreundergone fatty change . The arteriesexam ined, were o s sified, o r c ontained

0

In one c ase the m itral was affected ; In a grea t number o f casesaorta was diseased. Barth lo oks upon the interstitial haemo rrhagesthe walls o f the heart and the fatty change in its musc le as the

princ ipal patho logical facts o f the afl'

ection . He mentio ns , as

o c currences , ruptures Of the heart from the presence o f a co ronary aneurism and o f hydatids . He thinks it pro bable that the rupture o c curs

at the c ommencement o f the systo le, when the heart has to exert its

greatest amount o f energy . T he m o s t charac teris tic phenomena Of

its o c currence are sync o pe, a feeling o f suffo cation and anxiety , and o f

very vio lent pain at the lowerregion . Death o c curs , no t fro

materials ; m oderateShould any symptom s arise which threaten partial rupture o f th

the patient must be kept in bed, and drugs administereddim in ish the ac tion and so favour the gradual c icatrizationmuscular tissue PRep .) N o tes o f the ca ses are c onta ined inbo dy o f the paper.

Vedie (‘Gaz . des 187 1 , 145 ) gives a case Of ruptureheart in a woman affec ted with dementia, who se age is no t givebably due to degeneration o f the muscular fibres . Here

rent in the anterior wall o f the right auric le . NO murm

heard during life , tho ugh there were vegetationsaortic valves . She died suddenly, after beingfo r twenty-four hours .Thompson Lancet

,

’187 1 ,

‘

11,635) rec o

gentleman , set. 56, had been in go od healthtwenty-fo ur hours before he complained o fwell

,but towards m o rn ing he di

an inch long in the anterio r wallThe musc le had undergone fatty changefi

“

Beck (ih .,803) gives a case o f rupture o f the

act. 7 1 , in whom the muscle was also fatty . Hand apparently senseles s , about twenty m inutes befo re he died.

Matthews (ih .

,ih .) publishes the case o f a

given ,wh o had suffered for som e time with

disease . He died suddenly, and at the p o st m o rtem exam inatio n a

ho le was fo und at the base o f the left ventric le,about the s ize and shape

REPTURE o r HEART. 143

of a farthing, completely plugged with a black c lo t . This ho le wasapparently the result o f ulceration Rep ) , and must have existed fo rsome time, as the edges were c ompletely rounded o ff

,and the plug

'

o fclo t adherent .In the case rec o rded by Wiltshire (ih . ,

1872 , i , a woman,

zet. 57, who had during life presented symptom s o f ulcer o f the stomach ,suddenly died. In addition to the ulcers in the po sterio r wall o f thatorgan,

a rupture, three quarters Of an inch long, was fo und in the rightventric le . The musc le was markedly fatty .

Hughes (ib ., 11, 4 1) gives a case very like that Of Thompson . Theo f about 36, had been in his usual health , and had workedAt m idnight after retiring to b ed, he c omplained Of

nausea, and Of pain “as if his liver was being torn to pieces . ” So on

after he died. The auto psy showed a rent, half an inch in length , inthe wall o f the right ventric le, about midway between the apex andbase, c lo se to and parallel with the longitudinal sulcus . The walls Ofthe heart

,though no t exam ined m icro sco pically

,were soft and thin

probably fatty.

Lowe (ih ., 5 2 4) also gives a sim ilar case o ccurring in a woman

,set .

66,who after go ing to b ed in her usual health, wo ke with sickness and

vomiting, and died about seven hours later. Here the rupture wasfound in the left ventricular wall , immediately to the left Of ‘

and

parallel to the sulcus, and m easured about three quarters o f an inchin length . The substance o f the heart was so ft and flabby

,and pale

in c o lour.Watson (ih . ; 659) publishes a case o f rupture, to the extent o f aninch , in the wall o f the left ventric le, parallel with the sulcus . The

patient was a woman, act. 7 1 , and the muscular tissue o f the heart waspale and flabby.

Westc o tt Brit . Med. 1 87 2 , i , 554) records a case in whichthe symptom s o f nausea and vom iting, though as in some o ther c asesthey m ight have been premonito ry o f the m ischief in the heart

,are

doubtful from the fact that the patient, a man ,set. 65 , was more or less

a drinker,and the rupture m ight have been the result o f the vom iting

(Rep ) . In this case the heart showed the fo llowing appearanceson the wall o f the left ventric le were three lo ngitudinal fissures , thelowest extending thro ugh the entire thicknes s o f the wall, and m ea

suring rather o ver a quarter o f an inch in length internally the

rupture extended to three quarters Of an inch . S ome Of the musc ul ipapillares were ruptured, and the m icro sc ope pro ved the fatty degened

neration o f the mu s c le .

Sherman New Y o rk Med. vi , 345) publishes the case o f a m an

in whom,after being crushed between two railway cars

,the heart was

found ruptured in three places .

Neurosis of the Heart.

Nunneley Lancet,

’187 1 , i , 2 2 8) group s cases o f palpitation o f the

heart fo r c onvenience, and in the absence o f any scientific c lassification,10

146 REPORT ON PRACTICAL MEDICINE.

as fo llows—(a) cases o ccurring in personso f the heart, o r Of any o rgan havmg a

whether ( 1) in themenced, o r (2 ) thc onsiderable progress ; (6) cases of

.

dzstm e

pitation asso c iated with structural disease ;p lacements of the heart ; (e) palpitation as

c ertain c ondition s o f blo od—anaemia, go ut,ces sive sm oking or tea-drinking ; (f ) c asesexamples, two with autop sies , characterised by the o cc

pitation in definite attacks of sudden ac cess , and bywhich is observed between the perversion Of the heart’spatient’s sensations , and by the evidence of disturbed inno rgans connected with the heart . They fo rm the transition

,

from palp itation to angina pectoris . He disc usses (ih .

treatment o f palpitation ,which consists in the remo val Of

diate cause, regular hygiene and diet ; tonic s—iron, arsenicstimulants and ano dynes ; lo cal applications, such as

Althaus has advo cated the app lication o f the galvanic current to thepneum ogastric and sympathetic nerves in their c ourse

,and Waller

their c ompression in the neck by the thumbs Nunneley thinks thesetwo methods deserve study .

Mo inet (‘E din . Med . xvi, 608) discusses the patho lo gy ofangina pecto ris , and c onc ludes that it is a paralysis o ccurring in and

depending upon a weakened heart, as no o ther theory can ac co unt fo rthe symptoms and history o f the disease. As to treatment he rec om

m ends,during the paroxysm ,

difl'

usible stimulants and Opium ,hot

brandy and water, sinap ism s to the feet, and plac ing the hands and feetin ho t water ; and generally tonic s , galvanism and bleeding .

Under the term o f “ irritable heart,

”Da Co sta Amer. Journ . Med.

Sci,lxi

,1 7) describes a fo rm o f functional diso rder which he Observed

in upwards o f three hundred so ldiers during the American war. T hemen had been for a longer o r sho rter time in active service

,and c om

plained o f inability to march , on ac count o f dyspnoea, dizziness, palpitation

, pain ,and a feeling o f Oppression and tightness in the chest . In

numerous cases there was a history Of some disturbance Of digestion .

Though the m en seemed to be in go o d c ondition,this derangement of

the heart ’s action was very chronic,and the heart itself became in time

hypertrophied. In addition to the palpitation, an almo st c onstantsymptom was the sharp paroxysmal pain at the heart ; there was increased frequency o f the pulse, much afl

'

ec ted by po sition,&c . ,

a hardand jerky pulse, disturbance Of the nervous and digestive functions .

Both sounds o f the heart were equal and short, sharp and metallic , butgenerally unac companied by a murmur ; when the latter was present itwas usually systo lic . The causes o f the affection are analysed, thewriter enumerates certain preceding conditions Of ill health

,such as

malarial fevers , diarrhoea, hard field service, long marches . The predisp o sing causes m ay be m isuse o f to bacco and spirits, venereal excesses,syphi lis , exp o sure to sun

,&c . Da Co sta lo oks upon the affection as

the result of a disordered innervation on a heart rendered irritable by

148 REPORT ON PRACTICAL MEDICnvE.

traction o f the small er arteries . He sketches the role which the whitblo o d corptheory by quo ting Ranv1er and Cac co rding to whom the white blo o d c o rpuscles are fo und

the protrusions as well as on the free surface o f the internal

endarteritis .Kelly Path . So c . xxii , 93) records the case Of a chil

set.three m onths , which had been cyano tic from birth . A loud systo l

bruit c o uld be heard al l o ver the thorax, but m o st distinctly at ttapex. The child generally had a c onvulsive attack every mo rning.

the autop sy the ao rta was fo und arising from the right ventri c le, anthe pulm onary artery from the left. T he right ventric le was hypetrophied, the duc tus arterio sus c lo sed, the fo ramen o vale Open . Tl

valves o f the heart were healthy, the bronchial and coronary arterigiven Off no rmally.

Pye Smith (ih . ,xxiii, 80) gives a case somewhat similar. The patic

was a male child, 14 weeks o ld when it died, in whom there had beepersistent cyano sis since birth . T he heart was large fo r the ag

E xternally it scarcely appeared ill-fo rmed, the apex being fo rmed hthe left ventric le . T he right ventric le was hypertro phied, and halfthick again as the left . The septum was perfect . Arising from a sho

c onus veno sus on the right side was the aorta,with three perfec t sem

lunar valves , and two c o ronary branches it next gave o ff an innominatc aro tid

,and subc lavian branch , shewed an Open duc tus arterio sus :

the usual po int, and then turned down to the left side o f the chesThe o rifice and the who le o f the ao rta were small, but nowhere c o

stricted. The pulmonary artery aro se from the left ventricle,wit

valves larger than tho se o f the ao rta ; it was eno rmously dilated, as walso the right auricle, which was hypertro phied as well . There wascribrifo rm o pen ing in the fo ramen o vale. T he writer makes so

valuable rem arks o n the o rigin o f this no t very rare abno rmality .

DyceBrown Lancet,

’187 1 , i , 677) relates a case o f steno s is Of ti

pulmonary artery,fo llowed by tubercular phthis is , o c curring in

female, set. 2 5 . Bo th her parents had died Of phthisis . From the a

o f two years it had been no ticed that she was cyano tic . About tage o f 2 3 , she began to have a c ough , and died at last o f pro fufhaemoptysis . There was a very loud systo lic bruit during life . Thautop sy showed slight enlargement Of the heart, hypertrophy o f tl:right ventricle, atrophy o f the left ; slight thickening o f m itral antricusp id valves ; c lo sed fo ramen o vale ; steno sis o f the right c on

arterio sus , with a hard and dis tinctly cretified rim all ro und. T l

pulmonary valves were normal . About half an inch from this c ontracteo rifice, to its right, was a triangular o pening in the septum ve

triculo rum . Bo th lungs c ontained m iliary tuberc les and cavities . Hrefers to Lebert

’

a rem arks on steno sis of the pulmonary artery (se‘Med. Times and Gazette,’ 1 870 , Jan .

Peaco ck, Cases of Malfo rm ation of theHeart entire ob literation o r atresiathe orifice and trunk o f the pulmonary artery ; cyano sis ; death from canc rum or

(boy, wt. Zi) ; (2 ) great c o ntraction, o r steno sis, o f the pulm o nary artery ; defect ithe septum of th e ventric les and ao rta, aris ing equally from the two cavities ; I

MALFORMATION O E HEART—ANEURISM. 149

arteriosus, but that vessel rep laced by two sm all b ranches c onnected w ith thecyano s is (b oy, set. 1 7, w ith p late), ‘Trans . Path . xxii, 85 . Kellv,

‘MalHeart, defec tive Septum Ventriculorum ”

(g irl, set. ih . , 95 . King, “ Malou Of the Heart asso c iated w ith Caries o f th e R igh t Masto id Bone, and

LyonSuth erland, Med . Tim es

187 1, i i , 5 2 6. Mackey, Cyano s is , Murmur w ith th e F irst Sound of th etent Foramen Ovale (female ch ild, set. 5 m onth s), ‘Brit.Med. Journ ,

’1871 ,

Aneuri sm, &e.

Balfour E din . xvi, 704) records four c ases in illustration o f

some difficulties in the diagno sis o f aneurism c lo se to the heart . In all

the cases a pulsating tum our was present, with a systo lic o r doublemurmur at the base o f the heart ; but on po st-mo rtem exam ination no

aneurism was fo und, and only som e slight valvular m ischief in someHe calls attention to the

the diagno sis o f aneurism in

whic h they differed fromence o f al l the sub sidiary phenomenaneighbouring o rgans ; and (2 ) the

pulsations being less forc ible than tho se o f the

G . Johnson records the case o f a man , set. 33 , in whom aneurism Of

the aorta was diagn o sed by the aid Of the laryngo s c ope Brit . Med.

1871 , ii , The diagno sis was b orne o ut by the appearauces fo und p o st-m ortem . At the back o f the transverse aorta therewas a shallow pouch an inch and a half in diameter, c ommunicating withan aneurism ab out the size o f a walnut, which pressed backwards on thetrachea just abo ve its bifurcatio n ,

and nearly filling its canal ; thecartilages were eroded. The p o sterio r wall o f the aneurism was mainlycompo sed o f muc ous membrane, in which was an ulcerated o eninga quarter o f an inch in diameter, and p lugged only by a c lo t o f brine .

The symptom s during life were dyspnoea , dysphagia, and trachealstridor the latter was heard also o ver the upper dorsal spinous pro

had been formerly ahis death he had fallen into the

scitated. Since then he had hadmber, 1870 , he had haem o rrhageater he died suddenly. At thedistended with blo o d

,which came

aneurism on the c ommen cement o fy artery . It was the size of a sm all


were atheromatous . The writer givesdescription o f aneurism was found ; its

the pericardium were infiltrataorta was atheromatous . In

a rent through the internalClo se by and for 10 cm . alongcular c o ats were ho llowed out

c ommun icated through a rentarch with a c o llection o f c o a

into the left pleural sac , and slightly into theThe writer explains the pain in the right leg by suppo singsected po rtion o f the ao rtic wall was pressed agains t the 0

somewhat in the fashion o f an alternating valve, and so temporarilydered the outflow o f blo o d to the b o dy .

Other papers on aneurism and disease o f the aorta are

Tirifahy,“ Anévrysme de la Cro sse de l 'Aorta , ‘Presse Med. Belge, ’ 187 1 ,

Vallin,

“ Ob servation d’Anévrysme de l

'

Ao rta , ouvert daus la b ronche gau‘Rec . de Mem . de xm ii, Duchamp ,

“ Anévrysm e de

Lyon viii, 3 26.

s imulating Aneuri sm o f

Croft, “ Aneurism o f th

W illiam s ,“ Aneurism of the Arch Of the Aorta bursting

102 . Mo rris , ‘Aneurism of Abdom inal Ao rta wh ich had

neum , and sub sequently into the perito neal c avity ,

”ih. , 104Aneurism of the first p ortion o f the Arch Of the Aorta ,

”ih . ,

o f Ao rta ; Tum our o f Brain ,

”ih . , 1 1 5 . Baum ler, Case

nom inate Artery, press ing on the right Pneumogastric anxxii i, 66. King, Aneurysmand Embo lism o f left m iddledeath from an Aneurism of th

xvii, 4 18. Chartres , Case o fo f the Sac (in so ldier w ith

Ao rta ; adhes io ns o f the Heart and Pericardium tempo rary improvement under the

the subperitoneal space ; death on the twelfth day (man, set. 36, autopsy), ih . , 4 17.

15 2 REPORT ON PRACTICAL MEDICINE .

perly called “ pseudo -membrano us stomatitis . E co

had

o bserve the affection as it o c curred in an epidem ic o f

s tomatitis ” in a p ortion o f the garrison at Lyon during the late war .

Of twenty cases five presented well-marked ulcerative angina, in two o f

which the stomatitis was ab sent . T he patients'

c onditio n was generallygo od, but they c omp lained o f pain in swa llowing ; exam inatio n o f the

thro at showed o ne o r two m o re o r les s extens ive yellowish patches o nthe p illars Of the fauces and the tons ils . He lays great s tres s upontheir yellow co lour they were seldom grey o r blackish like the dep o sitin diphtheria . The underlying ulcerations were only slight, no t sur

rounded by any swelling o r induration o f the mucou s membrane,and

with no tendency to spread. The affection never extended beyond theisthmus o f the fauces ; generally it was un ilatera l . T he pain was o nlyslight . The submaxillary glands generally to o k no part in the dis -

l

turbance, tho ugh sometimes they were only s lightly swo llen . The

breath was always foetid. The patients c ontinued their o c cupationsthroughout the affection there was no pyrexia ; in one c ase o nly werethere s light febrile symptoms at the commencement. T he length Of

the angina depended on the treatment ; generally all symptom s dis appeared at the end o f a fo rtn ight . Change o f air and diet, gargles, andthe application o f nitrate o f S ilver, were the means employed.

Crisp , Cancer Of the Tongue and S imple Stricture of the (E so phagus (female,set. Path . So c . xxii, 1 28. Bristowe, Cancer inc luding Pharynx, Larynx,neighb ouring Lymphatic Glands and Lungs ”

(woman , int. ih . , 13 2 . Bradley,“ Adhes ion o f the Velum Pendulum Palati to the Po sterio r Wal l o f the Pharynx ;lo ss o f the ep iglo ttis, syph ilis , ” ih . , xxiii

, 10 1. T ho rowgo o d,“ Salivary Ca lculus

rem oved from the Orifice o f the Paro tid Duct,”ih . , 103 . Arno tt, Macro -

glo sais o r

Congenital E nlargement o f the Tongue, ih . 109 . Fa irlie Clarke, Hypertro phyo f the To ngue, ” ih ., 1 1 1 Id . , On a Case o f Un ilateral Atro phy o f the To ngue, ”Med -Ch in lv, 9 1 . Stroppa,

“ Faringite ed eso fagite flemmouo se c on sup

purazione delle tons ille ed edema acuto della glo ttide (th e las t the cause o f death,m an , set. Gaz . Med. 187 1 , 2 77 . Decaisne, Para lys ie du vo ile du palais,app lication de saugues, guériso n ”

(wom an , eat. 98, w ith s imple angina), ‘Gaz . des187 1, 2 78. Heidenhain, Ueb er die W irkung einiger G i fte auf die Nerven

der G landula Submaxillaris , ” Pfliiger’s v, 40 . Handfleld Jo nes , Treatm ent

o f Acute To ns illitis w ith Belladonna , ” Lanc et, ’ 187 1 , i , 1 2 . Id .,

“ Case o f Pseudo

to ns illitis , ” ih ., 504 . Lesegno , S tomatite éryth émateuse, ” Gaz . des 1872 ,8 1 . Packard, “ Report o f a Case o f Tons illitis asso c iated w ith Paro titis LaryngeTracheoto my, death ”

(b oy, set. 43} years),‘Amer. Journ . Med. lxiii, 404.

Priestley, “ On Cancrum Oris, ” ‘Brit. Med . i i, 5 7 7. Dujardin-Beaumetz,

Des Troub les de la Sécrétion Salivaire, ” Gaz . des 1872 , 2 1 1 .

Af ections of the as p hagus .

Po rro (‘Annal Univ. di c cxvn . 4 2 1 ) reco rds a case, withplates , o f c ongenital atresia o f the oeso phagus , the lower part Of whichc ommunicated with the trachea . A newbo rn female child

,a fter

beginning eagerly to suck , was suddenly seized with c ough , choking,

and regurgitati on o f the m ilk . T he intro duc tion o f a sound pro vedthe c ondition o f the tube . T he child lived two days . The upperportion o f the oeso phagus was found to term inate in a blind end 2 4 cm .

below the glo ttis : from the blind end a bundle o f muscular fibres was

AFFECTIONS or THE (E sornaeus, ETC. 153

o f the trachea to the bifurcationo pening between the lower portion o f the oes ophagusSome traces o f m ilk were in the stomach

,which

heir way thither thro ugh the trachea and the Open .

at slight expansion o f the right lung.

‘A Case o f S imple Steno s is o f‘

the (E so phagus fo llowed by Ep ithelioma84, oeso ph agus in upper part rather les s than an inch in d iam eter, dilatedat a po int 45 inches from c ardia, then ce gradually narrowed till it adm itteddinary lead p en c il, ep i theliom a o f dilated p ortio n), Guy

’

s Ho sp . RepClapto n, “ Cases o f S tricture o f the E sophagus”

(two , o ne autop sy, b o th

5 1 and ‘St. Thom as’s Ho sp . i i , 1 77, and see Bristowe’ s rep ort

t c ase,‘Trans . Path . xxii, 134 . Demarquay,

“ Rétre’

cissem ent de

on b eing found po st-m o rtem b etween th e latter and a large empyema ), Gaz .

1872 , 36. Greenhow, Cancer o f the (E sophagus , w ith a Fistulous OpeningTrach ea (m an, set. 59, ep itheliom a) ,‘Path . So c . xxii , 1 2 9. Thorow

go od, Cancerous Stric ture o f the (E sophagus (m an , set. 64, ep ithelioma), ib . ,

xxiii, I I 5 . West, On Syph ilitic Constriction o f the (E so phagus and Pharynx,”

Lancet, ’ 1872 , i i, 2 9 1 . Lowe, “ On Gastrotomy,”w ith c ase (o f a woman, set. 5 1 , in

whom the autop sy showed s ch irrhus o f the oesophagus), ih., 187 i , i i, 1 2 1 .

Af ec tz’

ons of the Stomach .

Flint (‘New Y ork vi , 40) publishes a paper on the patho lo

gical relations o f the gastric and intestinal tubules , based mainly on theresearches o fHandfield Jones , Wilson Fo x and Fenwick .

Hilgendorf and Paulicki (‘Vireh . Arch .

’ lii . I 53) fo und extensiveulceration o f the mucous membrane of the stomach

,with purulent

embo lic depo s its in the liver, in an ape (‘Cebus Apella The

animal had had diarrhoea for some time.

Ward Brit . Med. Journ .

’1872 . i . 185) reco rds the o ccurrence o f

medullary sarc oma o f the stomach in a man,aged 53 . He had no

actual pain,but a little uneasines s after taking fo od, and vom ited at

intervals a small quantity o f dark foetid, no t foecal, fluid. There wasno pain anywhere on pressure, nor was any tumour perceptible. Alarge fungated growth was fo und in the interio r and po sterior wall

,

o ccupying part o f the lesser curve o f the stomach,as well as the

pylo ric half. The pyloric orifice and greater curve were free,so that

fo od c ould readily pass . The cardiac section o f the stomach was not

dilated, and its walls were no t perce tibly thickened. Micro seo icexaminations o f the growth showed sma 1round nucleated and granular

ives two cases o f dilatation o fKussmaul (see last Repo rt, p .

ere was evidence o f stric ture o f

ged 36 and 42 . The sec ond case


indicating that the mucous membrane o f the stomach is in a

condition . In these cases (ih . xviii . 3 78) the stomach was em

between breakfast and dinner, at first o nce a day, then after the

o f two o r three days, and at last dispensed with altogether.

Schliep Lanc et, ’ 1872 , ii , 85 1 ) c ommunicated a

T he results o f the

ing out the stomach with go od effec t .accustomed to the tube, and there wasmuco us membrane into its Opening. This had o ccurred only o nce in

about six hundred applications o f the pump by the writer, and wasfo llowed by no bad c o nsequences .Crisp showed to the Patho lo gical So ciety xxiii , 137) a

dilated stomach from a woman aged 60 , who had suffered fo r someyears from indigestion , flatulence, ac idity and pyro sis . Her skin waso f a yellowish , coppery tint . She had also commencing cirrho sis o f theliver.

Habershon Guy’s Ho sp . xvi, 399) rec o rds the threecases —The first was that o f a woman ,

set . 47, who had had

vom iting after fo o d for a year,and had

feet and ank les swelled, and s o o n after

On admission ,there was anasarca o f t

ties,(E dema o f the abdom inal walls, and as cites . The h

were very feeble ; the urine free from albumen . About ashe was seized with vio lent pain in the epigastrium ,

so on

lapsed, and died. At the auto psy the abdomen was gres tl

and c ontained a c onsiderable quantity o f fluid, o f a m ilkyin the peritoneum . The

c o loured fluid, c onsisting

was very much thickened ; the sub

in thicknes s , white, fleshy,and oe

the thickening bec om ing graduallyfrom the pylo rus . The musculara quarter o f an inch in thickness at the pylo rus . Thereulceration at one po int as large as a threepenny-piece . T he

showed that “the greater part o f the white to ugh sub stanc

po sed of o rgani sed fibrous tissue, but in parts the substance

delicate tissue, with numerous small,sp indle- shaped cells,

long tails blending in the intercellular fibro id o r fibrillated textuThe muc ous mem brane itself was no t affec ted. The o ther o rgan s ,cepting the heart, which was small and atro phied, were no rmal .case is c onsidered to be one Of sarcomatous disease o f the pylo rus .the sec ond case

,a man, set. 45 , in whom there had been scarcely

vomiting, a large cancerous ulcer existed in the stomach ; it reathe pylorus, but the ulceration had rem o ved the Ob struc tion .

growth and ulcer


farctus ofKaempf the diarrhoea tubularis, pellicularenteritis, pseudmm embrano us enteritis o f later writers . The diseas e is charac terised byattacks o f abdom inal pain, fo llowed by the discharge o f mo ulds o r lo ngtubes . There may be but one attack m o re generally the paroxysm i sfo llowed by o thers at varying intervals . The sho rtest time fo r an

attack to last is, acc o rding to his experience, a.

week . The discharge i spreceded by distension ,

sense of burn ing, c o licky pains, and, at times ,a sluggish state o f the b owels , and suc ceeded by a c ondition o f c om

parative health . Palpitation o f the abdom inal aorta i s c ommon ; be

tween the attacks the bo wels are irregular, the patient snflers fromdisturbanc e o f his general health and nervous system,

and irritablebladder, with discharge of large quantities o f mucus . He gives theno tes o f seven cases . The membranous di scharge may come away withevery m o vement o f the bowels, almo st c ontinuously fo rmonths, perhapsyears . The m icro scopic examination o f the tubes passed shows atransparent, amo rphous , basement- substance, here and there indis tinctlfibrillated, and having imbedded in it granules , free nuclei , and sm

shrivelled, irregular, and rather granular cells . There are n o t manywell-marked epithelial cells , nor white o r elastic fibro us tissue cells .The chem ical reactions o f the membranes do no t throw much more lightupon them . He discusses the differential diagno sis o f the affec tion

,

lo oks upon the progno sis as unfavourable, and suggests rest in bed, application o f ho t water to the abdomen, slight purgatives , and an easilydigested diet, as m o st suitable during the attack . The treatment inpro tracted cases c onsists in a stric t régime, the disuse o f purgatives ,the steady use o f iron , ac ids, bismuth , injection of n itrate o f silver

,and

the application o f the c ontinuous current .Whitehead ( “ Mucous Disease, ” Brit . Med. 187 1 , i , 143)

gives an histo rical ac count o f the same afl'

ec tio n . Out o f 1 2 0 writers onthe disease

,he canno t refer to any half do zen who have described it by

the same name . He considers him self justified in stating that the cha

racteristic discharge from the bowel may be divided into three stagesMasses o f m o re o r less inspis sated mucus

,having the appearance

o f jelly . They are perfec tly membranous,and c ontain o nly the

merest trace Of albumen . (2 ) Tubular casts Of the gut, which o ccuras cylindrical sheaths , and also membranous shreds or flakes o f

various forms, which can be shown to be no thing m ore than fragmentso f the tubes in various stages o f development . These c ontain an abundance Of albumen, but no fibrin . (3) Membranous shreds o f lymph

,

mixed with blo o d and pus . This fo rm c ontains bo th albumen and fibrinin abundance, the latter in a fibrillated fo rm . Middle aged persons ,children ,

and Old people, may be held as liable to the disease in the o rderin which they are enumerated. It o ccurs farm o re frequently in femalesthan in men . Constipation , and the retention o f excreta within the

system , while it is a consequence, is also an exc iting cause o f the disease . It is generally Ob served in persons o f a c o ld temperament andrelaxed habit o f body, with feeble c irculation

,c o ld extrem ities , and a

peculiar whitish-yellow paleness o f skin ; in tho se who are apathetic ,and wanting in dec is ion and energy in their m o ral and intell ec tual character, though at the same time they po ssess a highly exc itable c ondi

APPECTTONS ORTHE INTEsTINEs. 15 7

tion of the nervous centres . Women who suffer during menstrualperiods, and tho se who are victim s to membranous dysmen orrhoea, arepeculiarly prone to it. It is o ften met with in women who are eitherchildless , o r have ceased early in their m arried life to bear children .

The m o st c omm on existing cause o f the malady is the irritation o f theintestinal canal, pro duced by crude and indigestible artic les o f diet .The writer discusses at further length the symptoms and the treatmentof “ mucous disease.

”

M cSwiney Dub . li, 396) writes on diarrhoea

,with green

sto o ls, in infants . As to their nature and c onstitution he leaves themstill unexplained. He thinks there may b e a

“c ongenital func tional

digestive weakness , ” by which a true gastro -intestinal catarrh would becaused

,fo llowed by acid fermentation

,and the action of the acids so

produced perhap s on the bil i-verdin .

Ro sse New Y ork Med. vi, 33 2 ) has found the best results

from the treatment o f cho lera infantum with brom ide o f po tassium .

The medic ine was usually prepared by mixing from twenty to fo rtygrains o f the brom ide with two o unces o f muc ilage o f acac ia ; the do sewas from ten dro ps to a teaspo onful according to circum stances . O cca

sionally a drachm o f krameria was added to the m ixture . The fo o d

given was the expressed juice Of fresh beef, seasoned with cayennepepper.

The Bulletin de l ’Acad. de Med.

’

(xxxvi, contains a discussion on gastro -intestinal puncture in tympanites, o pened by Bouley whoaflirmed the harmlessness o f the operation as practised by veterinarysurgeon s o n animals . Depaul , Piorry, Barth , and o thers, give theirexperience o f the o peration as performed on the human subject

,and

generally speak well o f its results .Beach (‘New Y o rk Med. xiv, 397) rec ords a case Of fatalperiton itis in a woman , set. 3 2 . The autopsy showed general periton itis

,the appendix vermiform is was greenish-black, and c ontained a

hard o vo idmas s made up o f o at-hulks ; between the external surfaces o fthe head of the ascending co lon ,

the ileum and the appendix was an

abcess tying together these parts o f the intestine.

Murchison Path . So c . xxii,146) gives a case o f the same

kind in a girl , set. 18,in who se appendix verm ifo rm is were found three

small c oncretions, the largest about the size o f a pea . She died o f acuteperitonitis due to ulceration and perfo ration o f the appendix.

Fo ns sagrives,“ De la Ponction dans la Pneum ato se Gastro -intestinale et Perito

néale,” ‘Lyo n vi ii, 155 . Pio rry,

“ Mem o ire relatif so it aux Co llections deGaz c ontenus dans les Cavités Abdom inales G aza -

ga s tras ie, Gaze-enle

’

ras ie, G az o

p e’

rito na s ie (as ie, abréviation d ’

ec tas ie), varietés de la Tymp anite des auteurs, so it a laPonc tio n de ventre, pratiqueé dans l ’intention d ’évacuer des Fluids Elastiques, ” Bull .de l

’

Acad. de xxvi , 943 . Wathen , On Pun ctures o f the Co lo n for the relief o fTympan ites ,” ‘Brit. Med . J 187 1, Braxton Hicks, “ Abdominal Puncturein Tympan ites ,” ih ., 5 2 6. Brown, o n same, ih ., ih . Saunders ,

“ Puncture of the Intes

tine fo r the relief of Tym pan ites , ” ih . , 583 (and see Ro oke and W ilks o n the same

sub j ect, ih .,

Chauffard, “ Ul cers s imp le du Duodenum ; perfo ration ; p ériton itegénéraliseé m ort,

” ‘Gaz . des 1871 , 3 73 . Barc lay, “ A Case of PerforatingU lcer o f the Duodenum (m an, set.

‘Lancet,’ 187 1 , i, 3 77. Wadham ,

“ A Caseof Perfo rating U lcer o f the Duodenum

”

(m an , set. ih . , 2 30 . Ro gers, PerforatingU lcer of the Duodenum”

(man, set. ib . , i i , 1 59 . Tyson,

“ Ulcerative Disease o f


stine” man set. 28‘Amer. Journ . Med. lxi ,

.

Weber,

‘s ghzl

sge

o

l

t'

ni

the App(endixVerm if‘o rm is ,” NewY o rk Med . Journ .

;xi v, 14 2 .

Chamb ers , “ On Ob scure Disease o f the Csecum ,

‘Brit. Med. Jo urn . ,o

7

E lliott, “ Ob scure Disease of Csecum ,

”ih Jackson, 05186:

Of.

Perl typhl ljtl s ,

ih . ,ii, 63 . Waldeyer, “ Myco s is Intestinal is,

” ‘Vi’

reh . Arch iv, 111,

Munch ,

Myc o sis Intestinalis und Mil zbrand,” Cen tralb l . , 187 1 , 80 2 . Weiser, Ueb er die

h dl des Durchfalls b ei Saugliiigen,

” ‘W ien . Med. 187 1 , NO . 35 .

B

Lia

ar

i'rel

zingnei Bamb ini, ” ‘Med. Gaz . 1872 , 30 . Gueneau de Mussy,

A

S imo nu I e ons Clini ues sur la Diarrhee Chro nique, Gaz .

,

des Ho p ., 1872 ,

Digrrhe’ e pal iilstre ; su

lfate de quinine, ” ‘Arch . Gén . , xix, 108. Hel p, Case o f

Abdom inal Intum escence, w ith Displacement of the Heart, from Fsecal Accumulatio n ”

(girl, set. ‘Lancet,’ 1871, i, 647.

Intestina l Obstruction.

Kuttner Vireh .liii

,2 74) discusses the patho logica lp

ro cesseswhich a portion Of invaginated intestine undergo es, befo re t e intussus cepted

part dies and separates , and befo re rec o very is complete . He

gives three cases with autop s ies , two in boys o f 18

, and one In a man

34years o ld. In al l the cases the first sympto ms o f Obstruction were

succeeded by diarrhoea : and the po st-m o rtem appearances in all threeshowed that after inflammation and necro s is the intestine bec ame againpermeable, but death o c curred, as it frequently do es , from perfo rationOf the intestinal walls and general peritonitis .The fo llowing cases must Speak for them selves ; they have been

arranged acc o rding to the c lassification given by Fagge Guy ’s Ho sp .

xiv,2 72 ; and see last ‘Bienn . p . 1 7 2 .

—Rep ) .1 . Cases in which the gut is plugged by its c ontentsS im on,

“ Histo ire d’une Oc c lusio n Intestinale complete par nu Calcul Bilia ire,quelques remarques sur le Traitem ent de ee grave acc ident,” Bull . Gén . de

lxxxi , 1 78. Meynott,“ Impaction of a large Gallsto ne in the Ileum ,

” ‘Lancet,’1872 , i, 5 76. Clarke, “ Large Biliary Concretion in the Il eum ,

” Med -Chin. Rev .,

lv, 1 . Prunac ,

“ Occ lus ion Intestinale Produite par l ’Ac cumulation de Matieres

Sterco rales . Emplo i de la glace intus et extra ,”Gaz . dc s 1871 , 486. Black,

Clinical Lec ture on Ob stinate Constipation and Ob struc tion o f the Bowels," Brit .

Med. 1871 , I , 83 .

2 . Intussusceptions'

o r invaginationsGreene,

“ Invagination o f the Large Intestine (ch ild, eat. 4} mo nths , auto p sy),Brit. Med. J 187 1 , i i, 2 79 . Gray, Repo rt o f a c ase o f Intus susc eption (ch ild,set. 5 years, autop sy) ,

‘Lancet,’ 187 1, i , 338. Hunter,“ Interes ting c ase o f Intus

susception ”

(ch ild, set. 9 m onths) , Lancet, ’ 1872 , i, 349 . Crisp .

“ Intussuscep tionin an Infant (girl, set. 8 weeks , auto psy), Path . So c . xxii i, 1 2 5 . Durham ,

“ Intussus ception o f the Rectum , w ith Adenomatous Growth (m an , set. 44 , co lo tomy,death four days later, auto psy) , ib ., 1 16. Kjelberg and Blix, Fa ll a t tarminvaginatio n h o s et spadt b arn ”

(fem ale ch ild, zet. 1 1 m onths, invag ination o f upper part o f

large intestine and p ortion o f the small intestine in descending c o lo n , and s igm o idflexure) ,

‘Hygiea,’ 187 1 , 97 . Moretti, “ Invagimento intestinale, No ta ed o sservazione,” ‘Anna l . Univ. di c cxvi, 542 . Herz, Zwei Fall e vonDarm invaginationbei Kindern ”

(1 , female, set. 6 m onth s , intussusceptio n o f transverse and as cendingc o lon , c aecum , and end of ileum , operation, death s ix hours afterwards ; 2 , female, ast .

7 m onth s, death), Oesterr. Jahrb . f . 1872 , i, 1 . Dub o is , “ Oc c lus io n intestinale, elimination d

’

une p ortion d ’intestin grele longue de 40 centimetres .

”Guérison,

(b oy, set.“ Bull. de l ’Ac ad . de xxxv, 849 . Halleguen,

“ Guérison depuisdix ans d

’une invagination intestinale avec expuls ion de 75 c entimetres d’intestin

REPCRT ON PRACTICAL MEb lCINfi.

Its cavity was found capable o f c ontaining only eighteen ounceswater, so rap idly had it contracted.

Chunder Roy (ih . ,10) reco rds a case in a Mahommedan, set. 30 ,

whom the intro duction o f a c anula was stream

o f the liver, which was transformed into a unifo rmwall o f hepatic substance no t thicker than half ano f hepatic tissue intervened between the po int o f the canulacavity of the abscess .Black, Ab scess of the L iver, Operatio n, Rec overy (man , set. Lan

i, 647. Ward, Suppo sed Hepatic Ab cess discharging through the Lung

ih ., 681 . Moxon ,

“ Ab scess o f the L iver, ” ih . , i i , 778 . Bennett,Ab scess ,” Brit. Med. J 1872 , i , 6 2 5 . Arnould , Ab ees et infarctus da Fo iede la rate,

” Gaz . 1872 , 4 . Gallard, Léc ons sur l’Hépatite et sur les Abe

du Fo ie, ” ‘Un ion xii,680.

(b) P arenchymatous Hep atitis—Acute Atrop hy .

Duckworth and Legg St. Barth . Ho sp . vii , 2 08) give no

Of three cases o f acute yellow atro phy o f the liver. A girl , set. 10,

been jaundiced fo r some days befo re admissio n,and after attacks

mo st furioulater. The

abdom inal c avity, numerous ecchymo ses were seen studding the omentumand c o lon . The liver was adherent by a few Old adhesions to the

diaphragm it did no t seem to be shrunken in size . T he c cecum and

c o lon were filled with scybalous masses o f a pale c lay-c o lour ; about aninch below the pylorus there was a small ulcer about the size o f a threepenny piece c o vered by a c o agulum o f blo o d. The stomach c onta inedabout fo ur oun ces o f cho co late-like fluid. T he bile-duets c ontained a

few drops o f a visc id green ish fluid. T he liver was flac c id,and felt

do ughy ; it was c onsiderably m o ttled and presen ted is lets o f a brightyellow c o lour

,which were c ontinued into the substanc e o f the o rgan ;

the aeini were quite distinc t . T he knife was rendered distinc tly greasy.

In the left lo be there was a light yellow staining o f the who le liversubstance and no ac in i c ould be made out. Sections o f the left lo beshowed under the m icro sc ope n o trace o f liver-cells, only an extremelydark and granular appearan ce, with large and small globules ofballs o f p igment abo ut the size o f a granulation -c o rpusc le. In the

sec tions from the right lobe a few hepatic cells remained undisso lved,

but in o ther respects their appearance was the same . The spleen wasso ft, the kidneys somewhat degenerated. The o ther o rgans werenatural . In the o ther two cases o ccurring in men, aged 2 3 and 19 ,no po st-m ortem exam ination c ould b e made. The seco nd Of these twowas a bro ther o f the girl first mentioned. A no tewo rthy p o int in con

nection with o ther symptom s in the diagno sis o f the disease wouldseem to be the o c currence o f severe hepatic pain s asso ciated with a

temperature either natural or even below the no rmal .Chamberlain New Y ork Med. vi

,2 65) gives a case o f atrophy

LIVER—ATROPHY—CIRRHOSIS. 161

of the liver in a woman aged 2 2 . The symptom s were icterus , blackvomit, coma, suppression o f urine ; death o ccurred after six days . T heliver weighed 2 lbs . 8 oun ces .Porter Amer . Jo urn . Med. lxi

, 409) gives no tes o f a case o f

the same kind in a merchant aged 2 with an account o f the po stmortem appearances foun d.

Clements Brit .Med. J 1871 , i, 367) reco rds the fo llowingA girl , aged 17, previously in go od health , became jaundiced, and c om

plained o f drowsiness . She then had persistent vom iting and becamedelirious, anddied c omato se . T he autop sy showed all the organs healthyexcept the liver, which weighed o nly 13 ounces . No t a trace o f hepaticcells c oul d b e found under the m icro sc ope.

Go odridge (ih . ,609) gives the case of a man

, aged 2 0, in whom acute

atrophy o f the liver c omplicated early secondary syphilis . Here theliver weighed only 30 7} ounces, and hardly a trace o f hepatic cells couldbe found.

Murch ison , Js andice from Gall-stones , fo llowed by Acute Atrophy of the L iver,with Puriform Depo s its (man, set. Path . So c . xxii, 159 . Moxon, Sub

acute Red and Y ellow Atrophy o f the L iver (wom an , set. 34, with p late), ih . , xxi ii,138. Wadham ,

“ Case o f Y ellow Atrophy o f the L iver ”

(m an, set. 2 8, autopsy)‘Lancet,’ 1872 , i, 288. Sieveking,

“ Acute Y ellow Atrophy o f the L iver, Death(man, set. 24 , autopsy), ih . , i i , 2 24 . Jones, “ A Case presenting the Sym ptom s of

Acute Y ellow Atrophy of the L iver, Recovery (wom an, set. Brit. Med. Journ1872 , i , 468. Zenker, “ Zur Path o logis chen Anatom ic der acuten gelben Leb eratroph ic (with plate), ‘Deut. x, 166. Steiner, “ E in Beitrag zur acuten

Atroph ie der Leb er aus Fettdegeneration (boy, set. ‘Jahrb . f. Kinderheilk

iv, 428.

(c) Interstitial Hep atitis—Cirrhosis .

Olivier Mémo ire pour servir a l ’histo ire de la Cirrho se hypertrophique, ” Un ion xii, 36 1) gives a case o f c irrho sis o f the liverin a man, set. 2 2 , a wine-seller. He had been a hard drinker since theage o f 13 at the age o f 18 he no ticed that his belly was swo llen ; hehad great digestive derangement, vom iting, ep istaxis , and jaundice.

His liver was enorm ous ly increased in size, extending to the umbilicusand to the spleen , which was also enl arged. After death the liver wasfound to weigh 2

°85 o grammes, and was m arkedly c irrho sed, the interlobular tissue having undergone considerable hypertrophy. The spleenand kidneys were also increased in size . The writer discusses the question o f c irrho sis, co llecting several cases of the affection in which theliver was enl arged, from o ther authors . He conc ludes that hypertrophicc irrho sis is a defin ite afi

’

ection, no t the first stage o f an inc ompletec irrho sis . It is m o re rare than the fo rm in which the liver is atro ph ied.

Like it, it is characterised anatom ically by chronic pro liferation o f the

cellular tissue and atrophy of the glandular substance from seom

pression ; but while in the atrophic fo rm this pro liferation ceases,in the hypertrophic fo rm it is c ontinuous, and to this incessantgrowth the enlargement o f the liver is due . In addition to the o rdinarysymptoms of cirrho sis, the hypertrOphic fo rm presents an enlargementof the o rgan, either general, or only partial . Acco rding to his

11


observation it is accompanied by an early and pro fo undthe blo o d, under the influence o f which o c cur various hasand jaundice more frequently than in the o rdinary fo rm .

cause is excessive alc oho lic drink .

Cheadle Brit . Med. J 187 1 , 11, 545) gives a c linicala case o f extreme c irrho sis o f the liver in a b oy set. 18. He

plained five m onths befo re o f debility and wasting, whichincreased. There was slight enlargement o f the liver anoedema o f the legs ; wild delirium ; paralysis o f them odic jerking of the lo f the liver was m o st

was an unusual quantp eritoneum about thetaking a c onsiderableThere was c ompletefound in the brain toGreen also Trans . Path . xxiii

,

terstitial hepatitis and o bstruction o f the

b oy, aged 10 . Twelve days before death hediced, drowsy, and screamed at intervals ; his pdied c omato se . The brain and tho rac ic o rgansThe stomach and small intestines contained a ve

dark blo od.

Moxon (ib .,153) describes a case in which supp

syphilitic dep o sits in the liver o f a man aged 2 9 .

o pened a large bile-duc t, so that its substance wasbile-p igment . The liver was extensively diseased,andm iddle regions many masses which at firs t s ighto f sarcomato us tum ours decaying in the centre . They were enc lo sedin what appeared to b e a fibrous cyst . From these soft masses therewere gummata in all gradations down to common depressed syphiliticscars with caseous centres . T he micro sCOpic charac ter o f the so ftfo rmations was not very definite—crowds o f cells larger than pus-cellsin a granular fil amentous matrix. One testis showed very cha

racteristic gummatous syphylitic o rchitis .Romm elaere, “ C irrh o se et Dége

’

nérescence amyIOIde du Fo ie (woman, set. 39,enlarged liver ; lardaceous liver, Spleen, and kidneys), PresseMed. Belge,’ 187 1 , 133 .

E ames , Cirrho s is o f the L iver ”

(drunkard, age not given) , Dubl . J li ii, 495 .Id “ Carnified L iver (man, intemperate, age no t g iven ; liver, h ard and dense,weighed 45 ounces), ih ., 496. Morgan, Syph il itic Depo s it in the L iver, U lcerationof the Larynx ”

(man , age no t g iven , gummato us depo s its in l iver and glands) , ih . ,

2 3 1 . Handfield Jones, “ Case of. C irrh o s is o f the L iver, Haem o rrhage and Asc ites,Paracentes is Tw ice, tempo rary am endment from Digitalis, Clinical Remarks (man,set. 34, fo rmerly gin-drinker), ‘Brit. Med. J 187 1, i , 2 19 . Th ompso n,

“ Cirrhos iso f the Liver ”

(man , set. ih ., 1872 , 1, 1 13 . Black , “ Cirrho s is of L iver, E rys ipelas (m an , set. 26, autopsy),

‘Lancet, ’ 1872 , i i , 1 17. Crisp, “ Inc ip ient Cirrho s iso f the L iver and Baggy S tom ach

”

(woman, set. Path . So c . xxi ii, 13 7.Liveing, Syph ilitic C irrho s is o f the L iver and Caries o f the Skul l, asso c iated withAmylo id Disease o f the Ab dom inal Viscera, Chronic Phth isis, and Ulceration o f the

Co lon ”

(man, set. ih .

,144.


He gives hishydatid one .

C legho rn March,187 1 , 1

,62 4) believes that a c onsiderab

ab cesses that o ccur in India are due to

place in Old hydatid cysts .Fagge and Durham , On

L iver, with an Addendum

p ar l’

ASpiration,

” ib ., 385 . Fox,“ Hydatids o f the L iver (in girl , a t. 14,

for six m onths w ith iodide of potass ium, rec overy), Brit. Med. J 187 1

Duckworth , “ Case of Hydatid Tum our o f the L iver, w ith Icterus (woman,

ih ., ii, 1 79 . Hett,“ Treatment o f Hydatid Cysts by s imple Tapp ing (wi

fine tro car, girl, set. ‘Lancet,’ 187 1, i, 2 5 7. Duflin ,“ Hydatid of

’

the L ivib ., 1872 , i i, 780 . Murch ison,

“ Multiple Hydatid Tum ours of the L iver (P)Peritoneum , in part successfully removed by operation ”

(woman, set. Path.So c . xxiii, 126.

(f ) Af ectione of the Bile-ducts , ao .

Decaisne (“ Sur nu Epidémie d

’

Ictére essentiel o bservé a ParisGaz . des HOp ,

’1872 , 4 ; Gaz . 1872 , 45 ) describes a kind

epidem ic of jaundice which o ccurred in Paris and its imm ed

b ourho od in elf had o c casion

reco riliaryductime .

Murchison Path . So c . xxii,15 2 ) gives the

very interesting case of bil iary fistula in the ab dominalset. 40 , from which bile was discharged. The patienttime the no tes were made .

Pugliese, De l’Hydrate du Chlo ral dans les Co liques h épatiques, ” ‘L

yon viii,

438. Nob let, Ob servation d ’un cas particulier d’Ictére, ” Gaz . des 187 1 , 594.

D’Ictere s imp le et du Catarrhe des Vo ies b il iaires (revue), ih ., 1872 , 1 53 . Féréo l,

Ietere, chron ique, Mo rt, Ca lculs du Canal cho lédo que, Hémo rrhagies internes(woman, set. 3 2 , autopsy), ih ., 2 59 . Villard, ‘Etude sur le Cancer des Vo ies b iliaires ,’Paris , 187 1 , pp . 104 . Cra cknell, “ Malfo rm atio n o f the Gall-bladder and HepaticDuct (m an, set.

‘Path . So c . xxi i, 163 . Nuiineley, Co ngenital Ob literation of the Hepatic Ducts (b oy, set. 6 m onth s), ih . , xxii i, 1 5 2 . Moxon , Syph iliticDisease o f the L iver suppurating and opening a Bile-duct (man, set. ih ., 1 53 .

T horowgo od,“ Gall-stone ”

(wom an, set. ih ., 1 5 1 . Murch ison ,

“ Sequel o f a

Case in which Gall-sto nes were discharged by a Fistulous Opening thro ugh the

Abdom inal Parietes (cf. ih ., xix, ib ., xxii, 154. Id., Fistulous Communiestion b etween the Gall-b ladder and Co lon ”

(woman, set. ih ., 1 58. Duckworth,Case in wh ich a Biliary Calculus was passed from the Umb ilicus, ” ib ., 15 7.

APEE CTIONs or THE LIVER AND SPLE EN.

9 ) Various .

Steffen Jahrb . f. v, 47) gives several tables of the size

the liver and spleen in children ,from birth up to 14 years of age.

Sc ience, March 18, 1872 ,e autho r states thatatic cells had under

gone mo re or les s fatty degeneration .

Roy Lancet,’ 187 1 , i, 10) gives a case o f rupture of the liver andleft kidney in a man

,set . 2 5 , the effects o f a fall . T he liver had three

or four rents, extending only a few lines into its substance, on its convex

Steiner Jahrb . f. Kinderheilk,

’ iv, 333) writes on the presence o f

blo od in the peritoneal cavity o f new-born children from superfic ialrupture o f the liver and sp leen . He remarks on the rarity of the affection, giving a case o f each , and c onsiders that congestive hyperaemia, andnot disease o f the liver

,i s the primary cause.

Other papers referring to the liver areDalton, “ Sugar Formation in the L iver, ” ‘New Y ork Med. xiv, 15 .

Bennett, “ Report on further E xperim ents dem onstrating that Mercury has no spec ialactio n on the L iver, ” ‘Brit. Med . 1871 , i, 1 . Hab ersh on,

“ Lettsom ian

Lectures on the Path o logy and Treatment o f Diseases o f the L iver, ” ib ., 1872 , ii , 3 1 .

Quincke, “ E in Fall von Aneurism der Leberarterie, ” Berl . Klin. 1871, 349 .

Ward,‘On some Afi ections Of the L iver and Intestinal Canal , w ith Remarks on

Ague and its Sequelse, S curvy, Purpura, Lo ndo n, 1872 . Fox,“ On some

Abnormal Conditions o f the L iver acc ompan ied by Jaundice, ” ‘Brit. Med. J1872 , 11, 8. Hab ersh on ,

“ Inflamm ation o f G lisson’s Cap sule, Oc c lus ion of VenaPo rtse, Blo od Cyst, Dropsy, Perito nitis ” (woman, set. ‘Guy

’s Ho sp .

xvi, 405 . So lowieff,“ V eranderungen in der Leb er unter dem E influsse der kiinst

lichen Versto pfung der Pfo rtader, ” 1872 , 337. Gee, Comp lete Ob literation of the Mouth s o f th e Hep atic Veins, ” St. Barth . Ho sp . vii, 144. Bo ckand Hoffmann

,

“ Ueb er das mikro chemische Verhalten der Leb erzellen, ” ‘Vireh .

lvi, 2 0 1 . Riegel, “ Zur Casuistik der Missb ildungen der Leber, ” ‘Deut.xi, 1 13 .

Af ections of the Sp leen .

Payne Path . So c . xxu,2 78) gives the fo llowing case of

Hodgkin’ s disease comp licated with acute tuberculo sis . A b oy, set . 10,

had presented during life great enlargement o f the spleen , which reachedfrom the seventh rib to the crest o f the ilium vertically, behind into thelumbar region ,

and in front almo st to the m iddle line . There was no

increase in the number o f the white blo od-c o rpusc les . He becamegradually weaker and died o f exhaustion . The sp leen was found tocontain num erous tumours o f the kind call ed lymphadenoma and

infarctus . Small tum ours o f the same kind were found in the liver andright kidney . The lymphatic gla

’

nds throughout the bo dy were affectedin the same way, and some o f them c ontained masses Of a soft caseousconsisten cy, which would, had they o c cupied the who le o f the gland, havecaused it to b e called scrofulous . There was, in fact, a distinct transition to the type o f disease called by that name. In addition there werenumerous mihary tubercles in the pia mater and lungs .

REPORT ON PRACTICAL MEDICINE.

globulus auf die Milz, ” ‘Deut. Arch x,

E inigeNotizen i’

ib er die Circulations-V erhaltnisse der 187

Afi ections of the P ancreas .

Pepper Amer. Journ . Med. lxi,159) gives the fo llowing

A man, set. 45 , o f very intemperate habits , first n o ticedhaemorrhage

the bowels in the early part o f 1 870 . This recurredthe last tim e in August o f that year, when there wasrhage into the stomach and bowelswas n o vomiting at any time. Atc irrho sis o f the liver was found ; thlarge amount of blo od, which hadthe ductus c ommuni s cho ledo chus .ing directly entered a cavityfilled with fluid blo o d and c lo ts . From a m icro scopicathe head o f the gland, which was enl arged and hardened, it weeluded that the spec imen was a well-marked case o f cirrho sis ofpancreas .

Af ections of the Peritoneum.

Hab ershon Guy ’ s Ho sp . xvi, 4 18) gives two cases w

show that abdom inal pain may be due to o ld adhesions betweenstomach and tran sverse c o lon . Bo th bec ome lim ited in theiandwhenever the o ne o r the o ther bec omes distended,

liver,stomach , c o lon , and duodenum . The gall-bladder c

irregular small calculi . In the sec ond case, also a man Of

pain without jaundice was present ; the patient passed anumber o f biliary calculi

,and digital examination gave the

duodenum and c o lon were adherent to the transstomach . The patient rec overed.

G iles Brit . Med. 187 1 , i, 447)between gono rrhoea and peritonitis in women .

gonorrhoeal matter may readily come into directtoneal membrane thro ugh the FallOpiancarriage this o ccurs with greater freedom, and in pro stitutes neglec tedgonorrhoea, though with les s fac ility, may in the same manner lead toperitonitis . The disease differs from puerperal periton itis in its sho rterduration and its usually successful term ination . He gives a few casesIn support o f his views .Do bson (ih.

, 4 75 ) draws attention to the fact that West in 1858 had

put fo rward a sim ilar view in Speaking o f acute uterine inflammation .

Dickinson Path . So c . xii,2 87, 2 96) publishes two very

interesting cases . In one, a b oy 35 years o f age, a tumour o f the

168"


Oil begins to appear in the casts and in the desquamated epJo hnson has

,however, seen cases o f reco very even after the

o f Oily casts and cells . The disease is essentially a curableprogno sis more favorable in the

o ld, and

infiuen

tion o f

able symptoms o f uraem ic po ison ing have been present .Gull and Sutton publish (‘Med.

-Chir. lv,2 73) a paper

on Bright ’s disease with c ontracted kidney (arterio -ca illary fibro sis) inwhich they arrive at the fo llowing c onc lus ions I

lliere is a diseasedstate characterised by hyalin -fibroid fo rmation in the arterio les and

cap illaries . (2 ) This m o rbid change is attended with atro phy o f the

subjacent tissues . 3) It is probable that this m o rbid change c ommonlybegin s in the kidney, but there is evidence o f its beginning primarily ino ther o rgans . (4) The contraction and atrophy Of the kidn ey are but

part and parcel o f the general morbid change . 5) The kidneys mayb e but little if at all affected, whilst the m o rbid change is far advancedin o ther o rgans . (6) This morbid change in the arterio les and capil

laries is the primary and essential c ondition Of the mo rbid state cal ledchronic Bright ’ s disease with c ontracted kidney. (7) The c linical history varies according to the o rgan s primarily and chiefly affected. (8)In the present state o f o ur knowledge we cann o t refer the vas cularchanges to an antecedent change in the blo o d due to defective renalexcretion . (9) The kidneys may undergo extreme degenerative changeswithout being attended by the cardio -vascular and o ther lesions characteristic o f the condition known as chronic Bright

’ s disease. ( 10 ) Them orbid state under discussion is allied with the c onditions of o ld age,and its area may be said hypo thetically to c o rrespond to the “

areavasculo sa .

”

( 1 1) The changes, though allied with senile alterations ,are probably due to distinct causes no t yet ascertained.

Johnson,in a paper read before the same so ciety Med. Times and

1872 , ii, 688 ; ‘Lancet,’ 1872 , ii, strongly Oppo ses theviews o f these writers, and maintains that the appearances no ticed bythem are due to distension of the coats o f the vessels by the reagentsemployed.

Ro berts Brit . Med. J 187 1 , 11, 5 2 1) Oppo ses Dickins on ’s viewthat the abuse o f alc oho l is n ot one o f the m o st important causes o fBright’ s disease, and gives a table o f the proportional number o f deathsfrom intemperance, from diseases o f the kidney, and diseases of the liverin different districts .

i, 1 16) relates the case o f a child, four months o ld,co vered With syphilitic psoriasis, who se urine was b ighl album inous,and who se face, arms, and legs were oedematous . T e micro sco pe

APPECTIONS OF THE xIDNE iI—NE PHRITIS . l 69

granular casts . Allnt o f mercury . He

sy.

lecture on a case o fin an intemperate woman, set. 46, who died o f

He gives some engravings o f the thickenedand the subcutaneous tissue. A large portionon a level with the lateral ventric le was exca

the outer margins of the c o rpus striatum’

and

tly broken down by the c lo t, and the blo od hadthe to rn septum into the left ventricle.

Lancet,’ 1872 , i, 103) gives a c linical lecture on a caseof renal disease ending in apo plexy in a woman who two years previously had had a left-Sided hemiplegia during pregnancy . She was

again pregnant at the time o f her death . The auto psy showed c on

tracted granular kidneys ; an enorm ous heart,weighing 19 o un ces with

healthy valves,and muscular hypertrophy o f the m inute arterio les . A

c lo t lay to the outer side o f the right c orpus striatum and thalamus,

and had torn through the fibres pass ing from them into the hem isphere.

It extended along nearly the who le length o f the ganglia, but did no t

turn round the anterio r end o f the c o rpus striatum . Its upper partwas on a level with the intra-ventricular surface o f these bo dies . Infe

riorly it was separated by a very thin stratum o f nervo us matter fromthe fissure o f Sylvius

,the source o f the bleeding being probably the

small branches of the m iddle cerebral artery here penetrating the brainsubstance .

Mo xon Brit . Med. J 1872 , i, 637) records a case o f extremegranular degeneration of the kidneys , with out hypertrophy of the heart .T he subject o f it was a man

,set. 72 , who se death was due to an ac c ident .

He thinks it very probable that some atrophic kidneys commence in a

c ongenitally imperfect structure, and supports his view by an Op iniono f Virchow ’ s Krankh . Bd. i) as to the continuation intolater life o f a p artia l foetal degeneratio n .

Murchison Path . So c . xxii,177) rec o rds a remarkable case

of fatal uraemia from atrophied kidney in a fo o tman, set. 18,o f temperate

habits . Ten days befo re adm ission into ho spital , having been previouslyhealthy

,with the exception o f pain and swelling in the thro at with

dysphagia five years befo re, he was seized rather suddenly with pain at

the pit Of the stomach, palpitations and dyspnoea on exertion . Five dayslater he complained o f shivering and pain in the lo ins, and after thatbecame very drowsy . On admission he presented no sign of chronicdisease, no no table anaem ia, no oedema . There was no thing abno rmal tob e disco vered in the lungs no eruption . His temperature was 954 ° F .

The urine drawn o ff by a catheter was c o lourles s, limp id, Sp . gr . 1 00 7,and c ontained a small trace o f albumen . The drows iness and the am ount

of urine increased ; the temperature remained below normal . On the

fifth day o f his stay in ho spital he died c omato se,after one o r two fits

of general c onvulsions . All the organs were found healthy except thekidneys

, o f which the right weighed 15; o z . and the left 5; o z . The

c apsules were adherent, and the m icro scope revealed the o rdinary

REPORT ON PRACTICAL MEDiCINE.

charac ters of granular c ontrac ted kidney . The blo od from the cerebralsinuses and veins c ontained urea .

Stohr Deut . viii, 467) employed transfusion in three cascai

o f uraemia . In the first c ase death was imm inent, but the patient livedthirteen days after the Operation . The sec ond died in Sixty-four hours ,and the third in Six hours after the transfus ion . In the first two theurine passed after the o peration c ontained blo od-Co louring matter, butn o blo o d-cells .Finney (‘Dub . J 111, 2 45) showed c irrho sed kidneys from a

man , set. 2 0 , who had passed urine in such large quantities as to sug

gest at first the p o ssible existence o f diabetes .Stewart,

“ Notes o f a Case o f Inflamm ato ry Bright’s Disease ; Fatal in th irdstage

”

(man, set . Brit. Med. J 1872 , i i , 94 (and cf . E din . J xvi,Ackermann ,

“ E in Fall von Parenchym ato se Nephritis m it Retentio n der

Cylinder in den N ierenkelchen und in N ierenb ecken (man , set. 2 0, w ith p late)Deut. x , 2 98. Dujardin o Beaum etz, and Hardy,

“ No te sur un cas d’

Urém ie,Unio n xiv, 130 . Moxon,

“ Case o f Gouty Granular Kidneys and IrruptivePneum onia ; Fatal by Acute (Edema of th e Larynx and Lungs ,” Lancet, ’ 187 1, ii,2 1 7. De Giovanni , Pneum on ite e Nephrite ”

(three c ases),‘Gaz . Med .

1872 , 2 61 . Lamb ert, Ophthalm o s c op ic Diagno s is of Brigh t’s Disease, ” ‘Lanc et, ’1872 , i , 3 2 1 . Gue

’

neau de Mussy,“ Etude sur le Tra item ent de quelques Album in

uries ,” ‘Gaz . des 187 1 , 4 73 . Handfield Jo nes , Cl inica l Lec ture on instances

o f Suc ces sful Treatment o f Degenerative Disease of the Kidneys, ” Med. Times and1871 , i i , 1 5 1 . Morris, “ On the Use o f the Turkish Bath in Album inurie,

‘Brit. Med. Jo urn . , 187 1, i, 193 . Bradbury, “ Remarks o n a Case o f Bright’sDisease, ” ih ., 1872 , i i, 37.

(b) Haematuria, (ya—Pavy Brit .Med. J 187 1 , i ,66) read to the

Clinical So c iety no tes o f a case o f paroxysmal haematuria , and exhibitedspec imens o f the urine . The patient, previo usly in go od health, wasseized, after expo sure to c o ld

,with nausea . His urine was the c o lour o f

po rter, but after rest in bed gradually became no rmal . E xpo sure to c o ldeleven days later bro ught on ano ther relapse . During the paroxysm s the

urine co ntained c o loured granules and crystals Of o xalate o f lime, but nocasts o r blo od-cells . He insists o n the case being distinct from one o f

o rdinary haematuria .

Stevens (ih . ,i i, 3 2 3) gives a case of “ interm ittent hmmaturia o f

m o re than twenty years ’ duration in a woman set . 75 .

Drysdale, Haematuria ending fatal ly (male , set. 73 , auto psy) , Med. Press and1872 , i , 36. Harley, “ E ndem ic Hsem a turia o f the South -E as tern Co as t of

Africa, ” Med.-Ch ir. liv, 45 . Ogle, “ Haematuria ”

(man , set. Lancet, ’187 1 , i i, 540. Cobb o ld, “ On the Development of Bilharzia Haemato b ia, to getherw ith Rem arks on the Ova o f ano ther Urinary Paras ite (the so -called Trichina cystic aof o ccurring in a Case o f Haem aturia from Natal ,” Brit.Med . J1872 , 11, 89 . Couto , Haematuria endemiea dos paizes quentes, ’ Bah ia , 1872 .

(c) Hyp ertrozohied Kidneys—Hydatids , &c .

—Ro senstein (‘Vireh .

liii, 14 1) has made experiments on dogs and rabbits,with a

y iew o f pro ving whether c ompen sato ry hypertrophy really takes placein one kidney when ,

from some cause o r o ther, the o ther kidneyc eases to perfo rm its functions . At the same time his experimentsthrow

. som e light upon the Share which the kidneys take in thefo rmation of urea . He starts with the fact that the size o f the


Ana lysis of Urine, &c .

Wernich U eber po stm ortaleHarnansamm lung,” 87 I

658) gives the results of certain experim ents . He remo ved the urine bymeans o f a catheter in a number o f women a quarter or half an hourbefore death at the auto psy he found from 30 to 50 grammes of c loudyurine in the bladder. In one case in which death to o k place almo stwhile the operation was being performed, and in which the bladderapparently c ontained no t a Single drop , o ver a table-spo onful was withdrawn with a catheter eight hours after death .

Falck Vireh . liii,2 82 ) finds from experiments that urea

inj ected into the blo od of dogs is passed unchanged with the urine inthe c ourse o f the fo l lowing hours . In a third section (s . 3 15) he givesa full historical review o f researches into the physio logy o f urea .

Seegen Pfliiger’

s v, 359) Oppo ses the views o f Brucke,Kuhneand o thers

,as to the presence o f sugar in normal urine

,and dec ides

from his own experiments that none is present in the healthy state,

and that c ontinued excretion o f even very small quantities is aec ompanied by all the symptoms o f diabetes .The same writer Brit . Med. J 1872 , i , 469 , and cf .

‘Cen

1872 , while c onsidering that Trommer’s i s the m o st delicatetest for sugar, asserts that its delicacy only ho lds go od with a wateryso lution o f sugar. Fo r this reason he filters the urine through animalcharc o al , which retains m o st o f the c onstituents o f the urine, m o reespecially the c o louring m atters and uric acid

,these substances pre

venting the prec ipitation o f the suboxide when it is fo rm ed. Havingfiltered the urine several times till it is c ompletely c o lourless, he washesthe charco al on the filter with a little distilled water, and to this water,when filtered o ff

,he applies Trommer’ s test . In this way he c an detect

0 1 per cent. o f sugar. Fo r quantitative analysis this filtration canno tbe performed, as the charc o al a lways retains a certain quantity o f sugarwhich canno t be remo ved again by washing.

Barc lay Lancet,’ 1871 , ii, I 1 7) writes on the chem ical relations ofurates and pho sphates . Y ears befo re, he hadbeen uzzled by the presenceo f pho sphatic depo sit in dec idedly ac id urine. n a case which he nowrec ords of severe diarrhoea the neutral urine c ontained a turbid flo c culent depo sit inso luble by heat , but disso lved by acid in c ombinationwith heat, inso luble also by ac id without heat. The m icro scope showedthe presence o f globul ar, highly retracting urates, with some crystals o foxalate o f lime.

Wanklyn Brit . Med. J 1872 , i , 133) Shows that , though thestrength of the urine in health i s subject to great variation ,

a certainrelation is maintained between the m ineral matter (salts) and the o rgan icm atter existing in the urine. In five Spec imen s o f healthy urine therewas never a larger propo rtion of o rganic matter than 1 7 times as muchas the m ineral m atter . In disease

,on the o ther hand

,the proportion of

organic matter is increased.

Traube Berl . Klin . 187 1 , 333) gives the fo llowing as differential tests in deciding whether blo od c ontained in urine has come

ANALY SIS OF THE URINE , E TC . 173

from the kidneys or the ureters . In the fo rmer case ( I) the micro scopeShows in the urine rings with co lourless c ontents , and a double o r

single outline smaller than no rmal blo od-cells . The altered blo o dc orpusc les do no t .o ccur in haemorrhages from the ureters . (2 ) T hec o louring matter o f the blo od-cells is so luble in urine

,and the latter

exhibits dichro ismus , on acc ount of the so lution in it o f haem oglobin freefrom o xygen . The first appearances are explained by the fact that theblo od-cells have lingered som e time in the s o -called tubes o f Bellin i .Generally cylinders also o ccur, compo sed o f blo od-cells in ro lls

,the

diameter of which proves them to b e true casts of the same tubes .Lab '

orde,“ Augmentation de l ’Urée dans certaines Maladies, ” ‘Gaz . Med 1871,

5 2 2 . Fowler, Quantitative Analys is o f Urea, ” ‘New Y ork . Med. J xvi, 2 77 .

Maly, Zur Bestimmung der Harns'

aure,”Pfluger

’

s vi, 2 0 1 . Salkowski, “ DieBes timmung der Harnsaure,

”ih ., v, 2 10 . Gaethgens , Zur Frage der Aussch eidung

freier Sauren dureh den Harri,”

1872 , 833 . Seegen,

“ Ueb er eineMeth ode,m in imale Mengen Zucker in Harn m it gro sseren S icherheit nach zuweisen ,

”ih ., 68.

Manassein ,

“ Ueb er Quantitative Bestimmung des Zuckers in diab etischen Harne nach

dem Untersch iede im specifischen Gewmhte des Harns vor und nach der G'

ehrung,Deut. x, 73 . L ib orius, Beitrage zur Quantitativen E iweissb estimmung , ” ih .,

3 19 . Treskin ,“ Die V eranderungen des Harries b ei laiigerem Verweilen in der Blase, ”

Centralb l 1872 , 147 . Jafi e, " Ueb er den Ursprung des Indicans in Harns ,”ih ., 2 .

Sob orow, Ueb er die Kalkausscheidung im Ham ,

”ih . , 609 . Etude sur une

Urine a Sédiment vio let ,” Bul l . Gen . de lxxxi ii , 2 60. Leb on, Sur la

Xanth ine et sa re’

ch erche dans les Calcus vesicaux,” ‘Compt. lxxiii , 47.Th omp son,

Diagno s is by E xam ination of Urine in ob scure fo rm s o f UrinaryDisease, ” Brit . Med. J 187 1 , i , 6. Tidy and Wo odm an, On Amm on ia in theUrine in Health and Disease, ” Lanc et, ’ 1872 , i , 809. Treskin,

“ Ueber die Anwendb arkeit der Methode zur Harn stofi bestimmung von Bunsen fiir das ‘Vireh .

Arch lv, 488. Ro sentein, Das Koh lensaure Amm on iak und die Uram ie,” ib ., lvi,

383 . Leared, “ Renal Calculi o f Cystic Oxide ”

(from woman, set.‘Path . So c .

xxiii , 165 .

G . AEPE CT IONS OE THE SKIN .

*

Genera l—Neumann (‘Wien . Med. 187 1 , 2 95) writes on the

changes found in the invo luntary musc les o f the Skin in cutaneous affectio ns . In vario la he finds always great increase in size, perfectly distinctfrom the true hypertrophy o f the musc les which Derby

,Ro ssbach

,

KOrner and o thers, have shown to b e present in lichen ruber, icthyo sis ,elephantiasis arabum , prurigo , and sclerema adultorum . It is impo ss ibleto dec ide whether in these cases we have to deal with an hypertrophy o ran hyperp lasia ; the individual fibres , as well as the rod- like nuclei, arevery much enlarged, and with them the who le muscle . Derby refersth is increase in Size to increased muscular exertion in pres sing o ut the

secretion from fo llicles with narrowed Op enings . In addition to thishypertrophy there i s atrophy of bo th musc le-c ells and nuc lei .Sm ith Dub . J lii

, 353) gives an analysis of 1 1 00 cases o fskin disease treated at the Adelaide Ho sp ital, Dublin,

since September,if S implic ity is no t to be laid to the charge of writers on diseases of the Skin . N0

one b ut the entom o logist can rival them in the smallness o f their distinctions : theirvarieties , like th o se o f insects , are already' distinguished by the names of the authors

who had the go od (I) fortune to describe them first—A. B . S .


1869 . The table includes examples of all the common,almo st all the

less common ,and one o r two o f the rare diseases, such a s

“alo pecia

areata,ichthyo sis

,kelo id, leucoderma , m o lluscum sebaceum , emphigus ,

purpura , favus, urticaria, and one or two o thers . ” (Som e 0 these m ayb e uncommon in Ireland—Rep .) T he writer touches upon what heconsiders to he p o ints of spec ial interest in some of the affections

, and

gives his treatm ent .Anderson Lancet,’ 187 1 , ii , 672 , &c .) gives an analysis ofconsecutive cases of skin diseases . A few o f the m o re interestingc ases are abstracted in the text below . Reference must b e m ade to

the paper itself for his c lassification o f his cases, which are dividedinto functional and organic diseases , the latter again frequently sub

divided. The m o st frequent affect ion o f the Skin by far was eczema,Of

which their were 2 875 ca ses erythema was m et with in 569 ecthymain 97 ; pso riasis in 83 1 acne in 342 ; pemphigus in 16 A few caseso f som ewhat rare o c currence are described.

Gueneau de Mus sy Gaz . des 187 1 , 4 13) writes on the

Symmetrical distribution of affections o f the skin ,with Special reference

to a case o f symm etrical erysipelas o f the face o ccurring in a malepatient . He thinks the case c onfirm s the law laid down by GravesClin . 2nd cd., ii, 3 2 7) that when this affec tion c ommences in

the m edian line it is develo ped symm etrically on each S ide of it . He

c omm ences his paper by asserting that this tendency to symmetry is alaw o f no rmal o rganic evo lution which reveals itself often under pathological c onditions . Fo r instance , decay o f a to o th on o ne Side is o ftenfo ll owed by decay o f the c orresponding to o th o n the o ther S ide ; thesame result o ccurs in affections o f the eye , in gout and rheumatism ,

in

the eruptive fevers, and in several cutaneous diseases . In his ca se theerysipelas c omm enced on the back o f the no se, and spread to the twosides symmetrically . On the third day it extended o ver the fo rehead,leaving two triangular spaces perfectly free. On the left S ide the

triangle c o rresponded with an Old c icatrix,the remains o f a wound

which had divided the integuments down to the bone . NO lesion was

present on the Oppo site side,and yet the erysipelas affected the '

same

p ortio n and dimensions o f skin,&c . ,

in the same fo rm as on thatsidq

. In seven days the erysipelas had disappeared, and the patient waswel

E rythema—Lipp ( “ Beitrag zurKenntniss des E rythema exsudativum

multiforme,Hebra , ” ‘Arch . f . Derm . und iii

,2 2 1) treated this

affection in 17 women and 2 men . It was preceded by pyrexia , rigors,malaise, and restlessness . It put on various appearances , smal l o r largenodes, patches resembling erythema annulare and gyratum , o r punotated Spo ts arranged in circles o r half circ les . In two cases there werebull se, and in one pustules . The affection attacked any part o f the body,and several times the mucous membrane

,pro ceeding to ulceration and

lo ss o f tissue . The feverish symptom s were present in alm o st all cases,

lasting fo r 18 days , and som etimes recurring. In one case there wasendo carditis and p leurisy, in n ine rheumatic symptom s

,and in several

cases c onstitutional syphilis .Wilson Brit . Med. J 34) gives a case of erythema


heap étiga e) that this m orbid condition is characterised by the preseno f various herpetic erupt ion s and by an acute lobular pneum on ia,which the name herpetic pneumonia shoul d b e given ; that the wthe affections named have a common bond in the disturbancenervous system ,

and that in febrile afi'

ections the appearance of

is alm o st always a favourable progn o stic Sign .

An acc ount is given Lancet,

’1872 , i , 3 9) o f a case

impetiginiformis under the care o f Hebra . The patient wasaged 2 5 , in the ninth m onth o f her second pregnancy. This was onlythe fifth ca se Hebra had seen . They all o ccurred in women at fulltime

, except one, which to o k place during the c ourse o f pregnancy ; thefirst four all term inated fatal ly . They all resembled one ano ther inbeginning in the region of the genital s , in the genera l difl

'

us ion o verbody in a later stage, and in the herpetic character (groups o f vesion the same inflamed base) which they presented. They wereaccompanied by fever and rigors . There was no restric tion to

course o f certain nerves .Bro adbent Brit . Med. 187 1 , i , 444) relates the case o f a

man ,aged 39, who presented on the right Side o f the neck an eruption

exactly resembling that of herpes zo ster o f the region o f the cervicalplexus

,and was at the same time the subjec t of factitious urticaria.

On drawing the back o f the finger-nail Sharply acro ss the Skin therewas produced imm ediately a broad line o f elevated hair-fo ll ic les ; thissubsided, and in two m inutes was suc ceeded by a S im ilar line ofelevated hair-ro o ts, but this time of a bright red co lour, which in fourm inutes and a half o r five m inutes had developed itself into a long,smo o th

,elevated wheal of urticaria, pale, with red margins . In ten o r

twelve m inutes the mark had almo st faded again .

P emp higus .—Bumstead (‘Am . Jour . Med. lxii

, 99) records thefo llowing case of pemphigus produced by the adm inistration o f iodideOf otassium . A man

,aged 2 8

,with an imperfect histo ry o f syphilis,

and)

with ecthymatous ulcerations on his legs, c om lained, after takingthree do ses

,each c ontain ing 2 0 grain s of the rug, o f heat and a

burn ing sensation in his face and bands,which were o bserved to be

reddened. Next day large bullw appeared on the expo sed parts of hisbo dy, and the patient affirmed that on three previous o ccasion s he hadtaken the iodide with the same result .P soriasis .

—Buck Berl . Klin . 1872 , 161) treats psoriasis asfo ll ows . The patient is placed in warm so ap-baths to so ften and lo o senthe epidermis the scales are then remo ved with a so ft brush , and theparts attacked by the eruption dabbed with acetic ac id, at first ones a

day, and afterwards as often and as strenuo usly as the patient is willingand able to supp ort the pain caused by the application . The dark co louro f the Skin caused at first so on disappears, and no scar remains .Po llo ck Lancet

,

’

187 1 , i , 683) records a ca se o f psorias is gutts ta ina woman , set. 43 . The disease had existed

,acc ording to her own

ac c ount, for the last twenty years . She strongly denied the po ssibilityo f any syphilitic taint . T en grains o f iodide o f po tass ium were given 'l

her three times a day, and a lo tion o f equal parts o f glycerine and water

PEMPHIGUS—PsoRIASl S—PIT ‘YRIASIS . 177

Was kept c onstantly app lied. On the fiftieth day there was n o rashwhatever, nor did it return .

P ityriasis .~—T . Fox Path . So c . xxii

, 3 13) Showed a man,set.

49 , who presented the c ondition originally described by Devergie under

the term pityrias is pilaris , ” in a perfect form . Six m onths previouslyhe had been attackedwith p ityriasis rubra,which within a week from itscommencement invo lved the who le body . After a general ton ic treatment o f six m onths ’ duration , the appearance o f pityriasi s pilaris waspro duced by the interfo llicular p o rtions o f the skin gradually assum inga healthy appearance, whilst every fo llicle remained plugged and dis

tended by little whitish, hard kno ts, the size Of pins ’ heads, and

slightly larger, which gave the surface, in certain parts, the feel andaspect o f a rasp o r nutmeg grater. This c ondition was o bserved at the

back of the neck, all o ver the back, o ver the chest,on the o uter parts

of the arms . In trac ing the disease from the lower limbs upwardstransitional stages between pityriasis rubra and pilaris were o bserved.

The disease began to break up into patches by the appearance o f

healthy islets o f skin here and there ; at o ther places were red papulesmore o r less iso lated. These latter were seen to b e pro duced by thedisten sion o f hair-fo llicles by p lugs o f epiderm is , which had been Shedfrom the lining membrane of the fo llicle . T he c o ndition found c o rn

pletely c onfirmed the truth of Devergie’

s description .

The same writer Brit . Med. 187 1 , i , 39 2 ) publishes a

clinical lecture on lichen ruberwith reference to a case o c curring in hisown practice . A wo man

,set. 46 , had been well up to the age o f 38,

when she became subject to bo ils and severe onychia . Two years and

a half later an attack o f lichen ruber c ommenced, w ith intense itchingand redness o f bo th eyes . At the end o f eighteen m onths the facebegan to redden c on siderably ; she c omplained o f excessive debility .

Nine m onths subsequently the redness had Spread to the head, neck ,and back

, and the reddened parts were somewhat s caly . So on the

who le body was affected. The rednes s was remo vable by pressure, andwas accompanied by burning and itching, espec ially towards eveningand m orn ing. The patient had suffered for the last year o r two from“neuralgia ”

in the shoulders and arm s, indigestion , and menorrhagia .

She was adm itted into ho spital in N o vember, 1869 . She was thenthin . At various times during the day the skin was the seat of c on

siderab le itching whenever the eruption was present ; this irritationwas paroxysm al

,lasting half an hour o r m ore. The c o lour o f the face

was deep red ; the Skin dry, wrinkled, and indurated, resembling xeroderma . The who le o f the scalp was reddened, and co vered by m inutescales ; the hairs were no rmal . From the back o f the head to the

scapula the skin appeared to b e disco loured by a m inute sub

cutaneous m o ttling, due to the presence of small reddish-brownpapules , o f the Size of p ins

’ heads, seated at the fo llic les,and

covered by exceedingly m inute white scales . T he front o f the who le o f

the chest and the abdomen was m arked by the sam e appearance, exceptro und the umbilicus and the lower part o f the abdomen . On the backof the thighs the papulation was still m ore marked ; the leg was veryrough below the knee the scales were c onfluent over the ankle . The

12


arms were affected in the same way . The nails were thin and theirro o ts red . The so les o f the feet and the palm s o f the hands were freefrom disease ; the extenso r surfaces of the fingers were red

, indurated,scaly

,and showed a disp o sition to crack . During her stay in ho spital

the patient impro ved greatly in every way, but had a relapse in May,1870 , from which she again reco vered. Fox c onsiders the case to beo ne o f well-marked pityriasis rubra, due to “

a general co ngestive con

dition , dependent up o n perversion o f the regulative influen ce o f the

nervo us system .

” There was “active dilatation o f the m inute blo od

ves sels,fo llo wed by effusion o f p lastic matter into and ab out the

fo llic les , hypertrophic growth o f the ro o t - sheath, and in som e cases o fthe papillary layer o f the skin . The treatment c ons isted o f alk aline andbran baths every n ight, with an oxide o f zinc and chal k lo tion app liedm any times a day. The i nternal treatm ent was directed to the pro curingo f S leep , and the regulation o f the general functions .P rurigo .

—Gay Archiv f . Derm . u . iii,I ) gives with a plate

the results o f his m icro sc op ic researches into the changes taking place inthe Skin in prurigo . He thinks that the different parts of the skin are

m o re o r less affected : the rete Malpighii, the hair-bulbs, sweat-glands ,c orium ,

and pap illae. The changes in the rete c onsist o f increase inthe cells o f the deep and some of the m iddle layers, due probably topro liferation . Their thickness extends also to the horny layer. T he

ves sels o f the hair- sac are found dilated and enlarged. The erectormuscles

,the outer Sheath of the ro o t

, and the pap ill ae, are greatly develOped. The sebaceous glands are generally dim inished in Size, andthe cells of the Openings h orny in character . On the o ther hand, thesweat-glands are dilated, their cells lo o sened from the m embrana propria , and their blo od-vessels also dilated. The same dilatation is fo undin the vessels o f the papillae the cells o f the c o rium are very marked,and are m ixed with branched and wandering cells the papillae are eu

larged. In con c lusion,he agrees with Neumann

,that the eruption of

prurigo is due to increase in young cells and the presence o f a fluidexudation in the tissue o f the papill ae.

E . Wilson Brit . Med. J 187 1 , i i, 34) records the o ccurrence

of a pruriginous eruption in a man,set . 5 7 . T he papul es were o f a kind

to be felt rather than '

seen,and apparently due to congestion and infil

tration o f the vascular c oat o f the fo llic les . The number o f spo tsnever exceeded ten or twelve . On scratching them an angular o r

square-Shaped exco riation remained,which dried up into a thin reddish

scab . The patient had formerly suffered from gout .The same writer (ibid i

,608) publishes a case o f prurigo m itis

from S imp le debility, ” in a woman, set. 2 1 . T he papules were foundchiefly in the face, a few on the fingers ; the who le eruption did notexceed ten or twelve Sp o ts .S c leroderma .

—Fagge Path . So c . xxii, 309) records the po st

m ortem appearances found in a woman,set . 64, the subject o f diffused

sc leriasis . ” She had bec om e latterly incapable o f taking nourishm ent, bec ause the skin of her face became SO tight that she was scarcely able tom ove the m outh . The skin wa s o f a yellowish c o lour

,hard and tightly

stretched o ver the t issues beneath, At tho se parts where the cuticle was


In reference to this paper Lucke Zur ethn is chenib . , 2 1 7) gives a case o f the same kind (“ paculo sis ” o f

ring in the Germanic race . A b oy o f n ineteen had fo r eight yearssymmetrical thickening o f the epiderm is o n the so les o f his feet andp alms o f his hands . He lo oks up on the affection as a lo cal one

,

o btained temp orary relief by remo ving the thickened epiderm is , byp licatio ns o f liquo r p o tas sas , by t inc ture o f io dine

,and by alka

baths .

Kelo icl .—Kohn Wien . M ed. 187 1 , NO .

He sho ws that Alibert was the first to describe thiso f the skin and that the name cancro id, afterwardb o re n o referenc e whatever to any res emb lanc

likenes s wh ich the p eculiar pro ces ses in kelo idc rab . Kelo id may b e described generallyimplanted in the Skin, Sharply defined, raised habo ve the surro unding level , tough and elasticl ike an byro sy red. It is generally painful on pressurepain exists o f a burning o r stabbing c haracterinnate pain Alibert and o ther writers make a d

and false kelo id. Its m o st frequent seat is the Skino f the trunk

,the sternum

,the mamma, the late

tho rax,the back , and the neck . From his own

Kohn finds that it o c curs in the pro portio n o f o ne

the o ther diseases o f the skin . T he general healththe disease . Little is known as to its develo pmento ppo rtunity seldom o c curs o f fo llowing it from its e

stages . At first smalflat

,o r slightly raised,

grew very S

s tationary .

o r undergo

Hebra have

in negro es espec ially,lashing with a whip . Sears in some cases may als o be the o rigin of

kelo id. It is no t always p o ssible to make a certain diagno sis betweenthe kelo id and hypertro ph ied sears . On making vertical sectio ns o fthe affected Skin , thick mas ses o f fibrous tis sue are seen runningparallel with the surface in the c orium

,no rm

enclo se it abo ve and below . Under the micro sc o penuc lei and nuc leated spindle- shaped cells

,the latter

abo ut the pro cesses o f the kelo id,where the fibres

m ore o f an o pen netwo rk . NO vessels o r glands a

m iddle o f the tumour.

T . Fo x Path . So c . xxii, 3 13) showed four tumours ranin Size from a small fist to a walnut

,which were remo ved from the

o f negro es in Jamaica . They are very c omm on among them ,

CHELOID—PAPILLOMA—E LE PIIANTIASIS . 181

ro sc ope the structure was that o f condensed

Jahrb . f. iv, 2 70) gives two casessom ewhat resembling the case o f papilloma

Path . So c . xx, The

unmistakably c onnected with some central nervous disorder.

ase is that o f a girl, aged 6 years , in whom papillomata wereo ver the who le o f the right s ide o f the breast, and the who lem . T he left half o f the n o se

,the left upper lip , a p o rtion o f

cheek , and the skin behind the left ear presented pap illomatousFrom the age o f 3 the child had had in c omplete epileptic

which became fully develo ped later. In the sec ond case, a

6 1,the growths o ccupied alm o st who lly the right half of the

pecially the axilla . He gives a m inute m icro s c opical ac c o untwhich he refers to increase in the pap illae, ac c ompan iedgmentation o f the skin . Bo th cases also must be ex

implication o f certain nerves ; the affection in the

l nerves,while in the

s in

It is lim ited to theences below

,in the

Oportionate hyper

ue,and elastic) o f

ith progres s ive atrophy o f the pann iculus adip o sus .pertPOphy is co nsecutive to that o f the subjacent vas

T he sweat-glands remained, while the hair-fo l lic les and

a o f

ngi

T he

lymphatic s and glands were unaltered. The subcutaneous vein s(saphena , &c . ) were varic o se, with their walls hypertro phied in p laces .

He throws n o further light on the cause of the hyperplasia .

Gay Arch . f. Derm . u . iii, 489) has exam ined into the

patho logy o f the sweat-glands in elephantias is . He finds that them orbid change c omm ences in swelling and pro liferatio n o f the epi

thelium,by which the openings o f the ducts are o b struc ted and the sac

swelled up . The cells which have undergone pro liferation degenerateinto an indistinct, homogeneo us , glassy mas s, in the m iddle of whichhom ogeneous c ircular structures sometim es appear, the smallest resembling c ells, the larger structureless . The glands themselves are

next seen filled with the same m aterial . The ducts are affected earlierand m o re severely than the glands . He gives a p late in illustration o f

his paper.

B attute (‘Rec . de Mem . de Med . xxvi , 1 1 2 ) reco rds the

o ccurrence of elephantias is in an Arab, set. abo ut 2 2 , stro ng b ut o f a


s cro fulous habit . Fo r three years his right fo o tderably in size (m easures o f his two feet are givenwas hard, o f the c on sistence of bacon ,

and t o o k nofingers . Its sensation was d

ana lgesia , but not anaesthesia .

ac count o fthe inco nven ienceto which he was put by thethe operatio n wa s performed. In addition to the his

generally found, the amputated fo o t presented a c o n

of small soft cheesy masses of different sizes , en c lo sed in a

brane and situated in the subcutaneous intermus cular tis sue .

the cysts c ontained a lso pus and blo od. He c o nsiders this “ tuberocaseous ” fo rm o f elephantiasis to b e n ot un comm o n in Algeria .

Anderson Lancet,

’

187 1 , ii , 844 ) reco rds eight cases of

phantia sis arabum , and three o f elephantiasis graeco rum . One o f

patients suffering from the latter was'

af

yo ung Highlander whonever been out o f the co untry ; ano ther was a b oy act. 1 2

,who

returned from India fo ur years befo re and the third was a girl act .

who had come home from Jamaica at the age o f seven,abo ut which

the disease c ommenced o n the face . The eruptio n c o nsisted fo r thepart o f yellowish -red tubercular patches o f different sizes , the senso f which was deadened.

M o l lus cum .—Balmanno Squire Brit . Med. Journ 1872 , i ,

c laim s to have disc o vered in m o lluscum c ontagio sum spo resro unded angles, which he believes to b e the spec ia l vegetable paro f the sebaceous glands , just as that found in chlo asma is o f thederm is , and that o f favu s and tinea o f the hairs .Duckwo rth (ih .

, 98) rem inds him that Hardy had already dsuch paras itic structures .Ferrier (ib . , ii, 682 ) c onsiders the existence of a vegetable p a

b e entirely negatived by the result o f his investigations . Wsecretion expressed from the fo llic lesand examined under the m icro sc o pe,

tents becam e sh

the soft centralunmistakeable to r fo rm from tho se o f p en ic ill ium . But

,

spo re-like bo dies were to be o bserved inrently multiplying by germ ination, an

mycelium . They were o f various sizesvacuo late aspect .he has come to th

actio n o f the causthe fo llic les , after several days ’ m aceratio n in ether, he hasdetec t any Spo re

-like b o dies,no r has he been able to pro duce

appearance by treating them subsequently with caustic po tac ould he find

r

any sp o res in the small and still firm tumours .attempted, With the sam e result

,to c ultivate the secretion in

so lution . He gives the case o f a child,aged nine m onths

,

twenty -two mo llusc ous tum ours were situated o n the lips, cheek ,

184 REPORT on PRACTICAL MEDICINE .

pro portion o f two to one in all casesin the eyelids first, extending in no t

parts they invariably begin near the

ably on the left side . It is probable thwhich the p igmentation o f the eyelids maythe liver is the m o st powerful .Dis ea s es of the hair—Crisp Path . So c . Tranlishes a case o f general alopec ia in a healthy man .

tim e at which he first n o ticed a smal l bare sp o t on hisnumbness o f the skin o f his left s ide from the armp it to thbald patches ap eared on the head, chin and cheeks

,and

till the who le o fPthe hair had fallen o ff his bo dy by abo ut

year . He had never had syphilis . His finger-nails Sp lit into layers ,and were rough , with num erous indentations and furrows , and o f a

bro wn ish c o lour. His to e-nails were no rmal . N o trace o f fungusc o uld b e fo und either about the hairs o r nails , on careful m icro sc o pica lexam inatio n . From his own statistics Crisp c o nc ludes that nearly allsubjec ts o f this c ompla int are stro ng, young, healthy m en ,

whilst inp orrigo deca lvans the maj o rity o f the

patients are females . Of the

seven cases o f to tal alopec ia he has c o lected, al l were males ; o f theeight examp les o f the disease, co nfined chiefly to the head and face

,

six were males,and two were females .

Berger Vireh . liii , 5 33) relates two cases o f premature greyhair. The first patient had typho id fever in 1866

,fo llowed six weeks

later by paralys is o f the right s ide o f the bo dy and o f the right fac ialnerve

,which disap peared in abo ut ten weeks

,when partial greyness

o f the right side o f the head and fa ce was no ticed. The seco nd patient,who had a number o f white ha irs under an abundance o f blond hair

,

spoke o f the white fo relo ck a s an heirlo om o f his family.

Pincus (‘Deut . 187 1 , 3) makes a sharp distin ction betweenalo pec ia on o ne side, and baldnes s and premature grey hair o n the

o ther . T he first is a true disea se o f the hair independent o f anyaffection o f the skin . Alopec ia simp lex attacks healthy pers on s betweenthe ages of 18 and 35 , and in the c o urse of five to fifteen years resultsin m ore o r les s extens ive baldness o f the s ca lp . On the o ther hand prem ature baldnes s affects only a po rtion o f the latter. He ho lds thata c c o rding to his investigations (‘Berl . Klin . Wo ch 187 1 , 333) theview that alopecia is the result

,in m iddle and advanced age, o f

atrophy of the skin , is erroneo us . He shows instead , from m icros c opical examination , there is really present an induratio n o f thecellular tissue .

P ara sitic afectionS r —Tilbury Fo x Lancet,

’1872 , i , 5 ) has detected

the tric oPhyton in the air o f the wards o f an institutio n in which an outbreak o f ringworm (300 cases , I 2 0 at one tim e) o c curred. As to treatment,besides cutting the hair, and blistering, he rec omm ends iso lation, go odfeeding, careful inspection , and, fo r the rem o val o f the flo ating germs ,dis infection o f the wards by burning sulphur.

The sam e writer (ih . , 187 1 , i , 536) des cribes the presence o f trichophyto n in a patient who se affec tio n began a s erythema marginatum,

and was complicated with urticaria and ecthyma .

PARASiTIC SKIN DISEASE S . 185

V anlair (“ Sur l

’herpés to nsurans ,” ‘Bull . de l ’Acad. Méd. Belge, ’

v,699) describes a fungus agreeing in s ome characters with that

des cribed by Ro bin as trickop lzyton tonsurans , in o thers with a fungusdescribed by Malm sten .

Anders on Lancet,

’

1871 , i i, 742 ) a sserts that tinea favo sa is muchmo re frequent in Sco tland than in E ngland ; he treated 160 cases o fit . “ The frequency o f favus in m ice , c o upled with the m o usy o do urwhich is o ne o f the characteristic s o f the c omp laint , renders it no timprobable that favus was o riginally c omm un ica ted to human beingsfrom them He m et with 1 78 cases o f ringwo rm ,

1 2 1 o f tineavers ico lo r, due to the presence of m icro spo ron furfur, and 197 o f tineadecalvans .Neumann (

“ Wien . Med. 187 1, 89) describes the differencesbetween parasitic and non -

paras itic syc o sis . In the fo rmer the hairsand their sheaths are affected first

,while in the non -paras itic fo rm they

suffer no change till later ; fo r instan ce, when the exudation into thehair-sac becom es purulent, the pus -c orpusc les make their way betweenthe sheath

,and s o lo o sen the hair. In the parasitic affection the deep

subcutaneous tis sue is affected, in the o ther only the hair-bulbs and

the c o rium . The o rdinary syc o sis may remain at a standstill fo rm onths and years . The paras itic one Spreads very rap idly . In two

cases Neumann found,in the neighbourho od o f the pustules and

papules , sp o ts and rings o f herpes tonsurans , and in ano ther casemycelia and c on idia . As in all these c ases he found traces o f herpestonsurans in some fo rm o r o ther

,and as this affection preceded syco s is

parasitica in 95 cases out o f 100,he c ons iders the latter as a form o f

the herpes affecting the hairy parts o f the Skin o f the face. As totreatment, depilation is no t necessary . He emp loys soft s o ap , suc ceededby the application o f U ng. Diachyli (Hebra) , weak s o lutions o f c o rro

sive sublimate,and sulphate o f c opper, o r an o intment c ontaining

crea-so te and sulphate o f c opper .

The same writer Arch . f. Derm . u . Syph iii, 2 12 ) gives theresults o f his experiments on the culture and development o f

achorion .

Kohn (ih ., 381) c onc ludes that c lin ical symptoms pro ve the identity

o f erythema multifo rme and herpes iris and c irc inatus . He describesthe fungi which he finds

,and recognises an o ther fo rm o f the affec

tion,which he designates as herp es tonsuran s maculo sus .

Monti (‘W ien . Med. 187 1 , No . 3 7) treats itch in childrenwith balsam o f c opaiba and carbo lic ac id. The fo rmer pro duces severeburning and rednes s o f the skin,

which lasts fo r ab out half an ho ur.

The superio rity o f the drug c onsists in the rap id cessation o f the

itching after the first inunction ; the disappearance o f the eruptionafter three o r four rubbings in ; and its cheapness as compared withPeruvian balsam . The carbo lic ac id (4 parts to 36 o f water

,o r to 1 2 0

of lard) is said to be better still . It is to be applied thrice a day, and

the scabies ought to be go t rid o f in from two to four days . If

eczema is present, the treatment must be persisted in for some timelonger.

Weinberg Ueber dieAmbulatorischeBehandlung Scabieskranker,


‘Wien . Med. 1872 , S . in cases where the affec tionslight

,and the patients ’ Skin tender, employs the usual fo rmula

Styracis Liq ., gjOlei Ol ivar., gij.

T o be rubbed in twice after a bath . He finds its effec t certain .

patients with a thicker Skin,he combines the styrax with soft so ap an

chalk3, Styracis L iq .,

Flo rum Sul ph .,

Cretae Alb ee, ana giss ;Sapon . ViridAxungiae Porc i, ana gj.

T o be rubbed in for two o r three evenings . This o intment hasgreenish-yellow c o lour, a doughy c on s istence, and agreeable smell ; one

to two ounces are suffic ient fo r one person ,acco rding to the severity o f

the affection . A bath is necessary o nly in persons o f a generally dirtyhabit . Patients treated with the o intment state that the itching isquickly m itigated by it, so that they go t a c omfo rtable n ight ’ s rest ;and after the second o r third inunction it disappears altogether.

O ther papers on diseases o f the skin are arranged as far as po s

sible in the o rder o f the preceding

Genera l —R . M “ One S ource o f Skin Diseases (so ap),‘Nature,

’ v, 464.

Mapother,“ Lectures o n the Treatment of Chronic Skin Diseases, ” Med. Press and

1872 , i, 2 9, &c . T . Fo x,“ Notes on the General Princ iples of Cutaneous

Therapeutic s,” ‘Lancet,’ 187 1, i, 64 1 . W ils on,

“ Lectures on Derm ato logy, ” ‘Brit.Med. 187 1 , i, 163 . Curran,

“ Notes o n Cutaneous Therapeutics , ” ‘Journ .

Gutan . iv , 35 .

E rythema—Buck, E rythemaNodo sum ,

”Berl .Klin . 1872 , 163 . Siredey,

Les Rapports Pathoge’

niques de I’

Erytheme noueux avec ls Rhum atisme, ” ‘Ann .

de Derm . et i ii, 24 1 .

E c zema .—Ta it, “ No te on the Cure of Inveterate E c zema in Ch ildren by Vac c ina

tion ,

” ‘Brit. Med. 1872 , i, 9 2 . W ilson , “ E c zema,”ih ., 1871, i, 163 .

Herp es .—Deshayes, “ Fievre h erpétique ”

(wom an , set. 5 Gaz . vi ii, 643 .

Broadb ent, L“ Herpes Frontal is giving rise to Co ntagious E rys ipelas, ” ‘Brit. Med .

J 1871 , i i, 34 . Frazer, On Herpetic E ruptions and A llied Affections ob servedin Dub lin during the year

‘Journ . Cutan . iv, 29 . Co utagne,“ De

l’Herpes GeneraliseFébri le,” ‘Ann . de Derm . et ii i

, 162 .

P emp lzigus .—Pico t, Pemph igus b ulleux tra ité par la Ouate et ls L inim ent

Oléo calcaire (two cases), Gaz . des 1872 , 1 7. W i lso n , Phlyctenous E ruption affecting the Hands , Ankles , and Buc ca l Muc ous Mem b rane, recurrent thriceyearly, repeated for several years ” (man

, set. Brit. Med. J 187 1 , i, 608 .

Imp etigo .—Devergie, “ Du Cancro ide, du No l i m e tangere, de l

’Impetigo , Ro dens

ulcéreux et non -ulc éreux, ” &c ., Bull . Gén . de lxxxi, 433 .

P s o ria sis .—Layco ck, Defective Cutaneo us Sens ib ility in Cases of Psorias is ,

‘Med . Times and 187 1 , i, 2 75 . Purdo n,“ On the Treatment o f Psoriasis byBals am o f Co paiva ,” ‘Dubl . J li

, 393 .

Li

6

c7i en.—Charpy, “ De la nature du L ichen hypertroph ique, ” ‘Ann . de Derm . ,

iv, 2

Ichthyo s is—Clarke, “ Ichthyo s is linguae, ” ‘Lancet,’ 1872 , i, 648. Ta it, “ On the

Patho logy of Ichthyo s is, ” ‘J ourn . Cut. iv, 2 63 .

R hinosc leroma .—S c leroderma .

—Geber, “ Ueb er das Wesen des Rhino sclerom , eine


transfo rmation, rather, than with Langhans, as some result of changein the c o louring matter o f the blo o d.

Seitz Vireh . lii,1 14) publishes the case o f a man

, set. 49 , in

whom were found multiple fibro -sarc omata o f the nerves . O ver variousparts o f his bo dy were numerous large and small tum ours

, which afterdeath were found to be neuromata . T he largest was the size o f a fist

,

and was situated on the left p eroneal nerve ; the next largest, the s izeOf a walnut, was on the internal c utaneo us nerve o f the thigh . Altogether there were twenty-two . On m icrOSCOp ic exam inatio n the smallo nes were fo und to b e m ade up o f fibrillar c onnective tissue ; in the

larger there was a tran s ition into round and spindle-celled sarc oma .

The nerve-fibres were no t enlarged, though in s ome places they had undergone fatty change. T he brain and its nerves , the spinal c o rd, thesympathetic , the cervic o -brachial and lumbO - sacral p lexuses , were n o t

affected. The patient died suddenly after being adm itted into ho spitalfo r strum ous steno s is o f the trachea .

Arno ld E in Beitrag zu der Lehre von dem Bau und der E ntwicke

lung der Psamm ome,” Vireh . ih .

, 449) describes three tum o urso f the meninges allied to fibroma , which showed extensive dep o s it o f

l ime- salts in the ribbon-like fibres o f the tissue, in the cell-gro ups lyingbetween them ,

and in the thickened sheaths o f the arteries and c apil

laries . Several o f the vessels c ontained thrombi . From his own oh

servation s Arno ld i s Oppo sed to the view o f Co rnil and Ranvier,a c c o rd

ing to whom this dep o s it o f lime o c curs in the psammom a and in the

no rmally o r path o logically dilated ves sels . T he firs t tu m o ur was fo und

on the dura mater,at the base o f the brain ,

in a woman o f sixty-five,

who had died o f cancer o f the stomach and oes o phagus . It was 6 by3

'

5 centimetres in size, and had caused n o symptom s during life . In

the seco nd case,a woman o f s ixty- seven ,

there was , on the o ther hand,

peculiar symptom s here the tum o ur was s ituated on the surface Of the

right c erebral hem isphere, c lo se to the longitudinal fis sure ; its size was4

°

5 by 3 c entimetres . In the third case, a woman o f seventy, who haddied suddenly from the bursting o f a dis sec ting aneurism o f the ao rtainto the pericardium ,

the tum o ur was round,with a diameter o f abo ut

2 centimetres,and was s ituate o n the right s ide o f the falx.

Zillner Vireh . Arch ih .,liii

,140) reco rds two cases o f the o c cur

rence o f c o llo id cysts,o ne in the under lip o f a b oy, aet. 10, which dis

appeared after being pun ctured the o ther case i s that o f a woman, act.

36, who had died o f typho id, and in whom the thyro id gland and thec onnective tissue in its immediate neighbourho o d were fo und to c ontainnumerous c o llo id cysts .Luschka (ih .

, lii, 3 2 3) als o gives , with a plate,two cases in which

c o llo id cysts were found in the larynx.

W agner Arch . (1. xiii, 1 ) c onc ludes his long ac c ount o f

tuberculo id lymphadenoma o f the various o rgans with a c omparison o ftuberc le with lymphadenoma .

Maier Zur Casuistik du Lymphoma , ih .

,148) publishes two cases

o f lymphomato us tum ours . In the first case,a man Of twenty -eight,

the diagno sis during life had been can cero us pleurisy . The right pleura l8210 was found filled With tumours of the size Of a fist

, mo st of them

TUMOURS . 189

springing from the pleura c o vering the lung and the diaphragm . Theywere cemented together by very vas cular adhes ions

,and there were

numero us large and smal l prom inenc es . The upper lo be Of the lungc ontained a tumo ur the s ize o f a fist

, a cavity in wh ich , the s ize o f a

walnut,c ontained serous fluid o f a yellowish-green c o lour . On sectio n

the tumours were greyish -white, and exuded a watery juice . In the

lower lobe o f the left lung were immense tum ours , o ne reaching thesize o f a child’s head. An o ther, the s ize Of a nut, existed in the wal lOf the right ventric le , and projected into its c avity . T he m ediastina lglands were large and dark . A half-degenerated tumo ur, the s ize o f a

walnut, was fo und in the to ngue . T he Spleen was enlarged, and c on

tained two tum o urs . T he m ediastinal glands and the o ther abdom inao rgans were healthy . The m icro sc opical characteristic s—tho se o f lym

pho-sarcoma - are given in full . In the seco nd c ase, a man o f sixty

nine, there was simple hyperp lastic lymph oma o f the mesenteric glands ,with two tumours in the pylorus . T he entire freedom o f the th orac icand abdom inal glands in the first case is remarkable. The writer c oneludes with the diagno sis between the scro fulo us, leukaem ic , and thesenew growths . In the sec ond case there was no increase in the whiteblo od- cells .Ro th (ih liv, 2 54) records the o ccurrence o f multiple lymphomata in

a woman o f fifty-three, wh o six m onths before death had been attacked

w ith diphtheria Of the fauces . Three m onths later she had catarrh o f

the bladder and o f the bron chi . T he auto psy showed great enl argement o f al l the glands in the neck , the axilla, m esentery, pelvis , gro in ,

&c .,with enlargement o f the spleen . T he glands were soft and mar

row-like, and were o f different sizes,from that o f a walnut to a pigeon ’s

egg. T he who le intestina l canal was studded with numerous m iliarydepo s its , c on sisting o f lymph-c o rpus c les , situated in the submucoustissue ; depo sits o f the same k ind were found in the mucous m embraneOf the larynx, the pelvi s o f the kidneys , and the neck o f the bladder.

The kidneys were greatly en larged, and c ontained grey m iliary and

larger masses , which, under the m icro sc ope, appeared as round cells ina vascular stroma . In the brain were numero us micro scopical depo sitso f round c ells in the interlo bular c onnec tive tissue . There was no in

crease in the number o f the white blo od-cells .Birch-Hirschfeld Zur Cylindromafrage,

” Arch . d. xii,167)

describes a peculiar tumour rem o ved from the abdom inal c avity o f a

man,set . 59 , who had died o f phthisis . It was the Size o f a fist

,and in

c onnection with the base o f the verm iform appendix , and sent threecylindrical pro cesses with knobbed term inations into the cavity o f the

pelvis . The tumo ur and its m icro sc opical charac ters are described atlength ; and from the who le he c oncludes that the anastomo sing net.

work o f which it was c ompo sed was the relic o f o bliterated vessels,and al l the o ther growths in it pro ducts o f changes in their adventitia and that the hyaline degeneration which the growth had undergone was caused by the depo sit Of (probably emigrated) lymph -c o r.

pus cles , which had partly been transfo rmed into Spindle cells . The

starting-po int o f the tum our must have been the vessels o f the serousco at o f the vermifo rm appendix and neighbouring parts . He refers


to the published cases o f cylindromatous tumours , and c alls the o ne

described by himself angioma muc o sum pro liferum .

De Morgan,“ On the Origin o f Cancer, ” Lancet,’ 187 1 , i i , 6 . Arno tt, “ No tes on

the Path o logy of Malignant New -

grow th s : Carc inoma,” ‘Med . Tim es and Gaz .

, 187 1 ,i, 566. S ilver, “ Canc er b eg inning in the Inguina l G lands and extending upwards

along th e Lym phatic s into the Chest ”

(m an , act. ib ., i i, 769 . Co ats , “ T he

Struc ture o f the Myxom a and S arc oma, w ith Illustrative Spec im ens ,” ‘Glasgow Med .

J iv, 35 . Kaschewarowa -Rudnew a , Myom a S trio c el lulare seu Rhab domyoma

Myxomatodes Vaginae, ” ‘Vireh . Arch .

’l iv , 65 . Lang ,

E in Beitrag zur Kenn tnis s

der sogenannten Dermo idcysten,” ih l iii, 1 28. Armauer-Hansen,

“ Beitrage zur

normalen uud patho logisch en Anatom ie der Lym phdru sen , ih ., lvi , 280 . Perls ,Beitrage z ur Ges chwulstlehre,

”ib ., 43 7. Acker, Zur Pathogenese der Geschwulst

m etastasen,” ‘Deut. x i, 1 73 . Neum ann , Ueb er Sarc ome m it endo thelialen

Zellen neb st Bem erkungen ub er die Stellung der Sarcome zu den Carcinomen,

”

‘Arch . (1. xi i i, 305 .

I .

—CLIMATE ANDa

HEALTH-RE SORT S .

Ho lden O strac ism fo r Co nsumption ,

” ‘Amer. Journ . Med .

lxi, 1 0 7) asserts that the efficacy o f a long sea voyage is graduallybecoming m o re evident . The testim ony even o f tho se who have s implycro ssed the Atlantic o n their way to Italy, Madeira, o r Syria , will bealmo st universally fo und in its favour. Within a week after lo singsight o f land the c ough frequently subsides o r changes in character,dyspnoea is relieved, the appetite returns, and with it a sense o f new

V igour and ho pe o f rec o very . The voyage to Cape Horn,Sydney, and

thence to San Franc isc o by Sea , &c . ,offers all the c ombined benefits to be

lo oked fo r. As to American reso rts, he recommends Flo rida,Aiken,

South Caro lina, and Minneso ta . At the same tim e the o bjec t o f hispaper is to “ pro test agsinst the growing recklessness in sending patientswho fail to improve out of s ight . ”Mac laren Med -Chin xlvn ,

193) writes o n a long sea voyagein phthisis pulmonalis . He gives sho rt n o tes o f his own and n ine o thercases , and relates some useful facts as to the voyage to Australia .

From the time Of leaving E ngland the temperature steadily rises un tilthe vessel is c lo se on the line, generally in a m onth o r five weeks ; itthen gradually falls, until the m o st southerly po int in the passage isgained, which may, perhaps , be in ano ther m onth ; during the remaindero f the time it rises Slightly until Aus tralia is reached. He sketchesthe go od hygienic c onditio ns in which the patient is placed—purecontam inated air

, pure water, absence o f drains, go od fo od, with generally a large proportion o f fat. But a sea voyage is a rough remedy,and it canno t be expec ted that it will be benefic ial in every cas e.

”

Rattray Pro c . Roy. xviii , 5 2 9 ; xix, 2 95) describes some of

the mo re important phys io logical changes induced in the humanec onomy by change o f c limate, as from temperate to tro pical, and thereverse . Tropical c limate causes lo ss o f weight and depression o f bo thmental and bo dily energy . With hard work and diet o f salt meat thelo ss is greatly increased.

Sésary De la temperature de la ville d’Alger au po int de vue des

Maladies Chroniques de la Po itrine Al ger, 1872) shows that thestudy of maximum temperatures is o f more imp ortance from a medical

REPORT ON PRACTICAL MEDICINE.

Lis t of E rra ta in last Rep ort on P ractica l Medicine.

Page 50 , line 10 from top ,f o r lanula read “ lunula .

5 2 , 1 af ter suchung dele full stop .

59, 7 read ring.

”

66, Seidel’s cases sh ould prob ab ly have b een inc luded under typho id fever.

73 , line 3 from b ottom , f o r“c ons iderab le read “

c o ns iderab le.

”

88, 8 f o r“sudariparous read s udoriparous .

92 , 3 from to p, af ter Gaz .

”read 1869 .

102 , 19 f o r“ i ” read

103 , 7 af ter Hysterie ” dele full stop .

1 19, 1 7 f o r Acetus read “ Acutus .

”

1 19, 4 from b ottom , f o r retinas read Retinae.

13 2 , 14 from top ,f o r Thus read “ In the sam e way .

139, 13 f o r pas read par.

”

147, 24 f o r“ Amb rée

’

sche read “ Aub ree sche.

185 1 5 from b o ttom , f o r E nto zo ares”read E nto zo aires .

187, 18 from tOp ,f o r“ latter ”

read “ delirium .

187 , 1 7 from b o ttom ,f o r these read there.

Ih .

”is in many p laces printed for Id.

”

The fo llowing errata in the present Repo rt have been o verlo okedPage 34, l ine 24 from b ottom , f o r appearances read appearance .

40, 2 1 from top ,f o r abaissmeut ” read “ab aissement. ”

4 1, 19 f o r Burke ” read Barker.

”

44, 2 from b o ttom ,f o r Seltener read “seltener.

47, last line, af ter emp loym ent”read “ in .

”

50, line 14 from b o ttom , f o r Dr.

”read De .

70, 7 from top , af ter 1872 read pp .

73 , 10 af ter“ Beitrag ” dele full stop .

79, 1 1 from b ottom, fo r Des Paras iten ”read Die Paras iten .

RE PORT ON SURGE RY .

WAREN TAY,

ASSISTANT -SURGE ON TO THE LONDON HOSPITAL , E TC.

Anaesthetics—The number o f deaths which have o c curred, lately, fromchlo rofo rm ,

the repo rted immun ity Of ether from such ac c idents , thevis it Of Dr . Joy Jeffries to the Ophthalm o lo gical Congress held inLondo n

,and his prac tical dem o nstration s o f the m anner in which ether

is given in America , have c ontributed to exc ite,anew, the dis cus s io n as

to the relative m erits o f the vario us anaesthetic s , and to lead to a trialo f ether on a large scale in this c o untry . All the journals have c on

tained artic les on the subject,and papers have been c o ntributed by

many administrato rs .

In the ‘Lancet ’ fo r N ov. 16 and Dec . 7, 1872 , is a report on anaes

thetic s and anaesthes ia . In the fo rmer number is an ac c ount o f a case,

published in the New Y o rk Medical Rec o rd, ’ o f a dea thfrom the ad

min is tration of ether. This case is also n o ted in the o ther j o urnals .

E ther and chloroform—Mr. W . Haward gives the fo llowing c onc lus ions as to the effec ts o f chlo ro fo rm in fatal cases That in the

maj ority o f fatal cases the m o de o f death is by failure o f the heart ’saction . (2 ) That this failure is generally sudden . The chief dangerfrom chlo ro fo rm is a sudden arrest o f the heart’s actio n

,and this danger

do es no t appertain to ether. It has been shown,by Dr. Snow

,that it

is impo s s ible to paralyse the heart by ether inhalation . E ther, pro

bably, even stimulates the heart . It has the advantage o fbeing antago

nistic to the effect o f the sho ck Of an Operatio n . Mr. Haward th inksthat there is less liability to s ickness , after the adm inistration o f ether

,

than after ch loro fo rm . The chief Objection to ether is the greaterquantity that is required, but this , to some extent

,may b e o verc om e .

T he m o st c onvenient fo rm o f apparatus is a c one o f felt,c o vered with

Oiled s ilk o r mac into sh,into the upper part Of which is fitted a piec e

Of sponge, wh ich c an be changed o c cas io nally for a sim ilar p iece kept ina basin o fwarm water. A shallow gutter running ro und the ins ide o fthe c one prevents the ether from reaching the patient

’s face . An aper

ture,the s ize o f which can b e regulated by the finger, adm its m o re o r

les s air as may b e required. T he princ ip les to b e attended to,in the

adm inistration o f ether,are T o s catter the ether o n to a surfac e

which allows its evap o ration witho ut much absorption . (2 ) When the13

194 RE PORT ON SURGE RY .

temperature o f th is surface is s o much reduced that thes lowly evapo rated, to change it fo r a warm o ne . (3)vapour freely, at first, s o as to bring the patient under itsquickly a s po s sible, by wh ich the tenden cy to

T he two chief inconveniences , w

b ility Of the vapour must als o be b o rne in m ind. A tablec ases Of deaths from ch lo ro fo rm is given ,

and als o a tablewhich ether was adm inis tered, n inety-seven in number. Iwas there after- s icknes s

,and, in that c ase , the patient o nly vo

an hour after the Operatio n . M ed -Chin lv ,Anaes thetic s , by Dr. Jones Brit. Med. J No v. 2 3 and 30 ,

Ch lo rqfo rm wad its adm inis tra tion . Dr. Vivian Poo re Lancet ,’ O ct . 1 2 , 2

16, Dec . 14, 1872 ) c ontributes c lin ica l rem arks o n chl o ro form and its a

tratio n .

Ct rof orm ac cidents , by J. T . Clover Brit. Med. J July 8,A c linic al lecture on Dea th f rom chlo rofo rm , by Mr. E rich sen, is g iven in

Med . June 8, 187 2 .

T he adminis tra tio n of ether . by Jo hn Couper Brit. Med. No v. 30 , 1

T he a dminis tra tion of ether, w ith a figure Of an apparatus, by Dr . Mo rgan

Med. No v . 2 3 ,

E ther as an a naes thetic , by Dr. Morgan Brit. Med . J O ct. 1 2 ,

T he adminis tratio n of ether, by G . E . Norto n Brit. Med . J Dec . 7, 1

He figure s an apparatus .

E ther v. Ch lo rof o rm , artic le in Brit. Med . J Nov . 2 , &c . , 1872 .

Nitrous oxide still ho lds its p lace as a safe anaesthetic , adaptedrate , fo r sho rt Operations ; chiefly the extrac tion Of teeth . Ajust now repo rted from E xeter, in which death fo llowed the adm

tion o f nitro us o xide , but thes ome m inutes after serious a l

m o rtem . T he case will pro bably remain doubtful as to the exac twhich death o c curred. Brit. Med. Journal

,

’

&c .

,Feb . 1

,1873

Antisep tic surgery—M r. Lister’s address , befo re the Brit

As so c ,enters , fully, into the question O f antis eptic surgery .

been published in all the medical j ournals,and

,therefo re

,

ac cess ible to m o st readers .

quarters . Numerous cases Of suc cessful antiseptic treatment haveno ted in the vario us j ournals . Antis ep tic gauze .

- Mr. Lis tes cribes it as being a lo o se c o tto n fabric , the fibres o f which are im

nated with c arbo lic ac id,securely lo dged in ins o luble resin

,which

the c arbo lic ac id with remarkab le tenac ity,while

,at the same ti

little paraffin is added to prevent the adhes ivenes s,whi

c arbo lic ac id and res in wo uld o therwise po s ses s . fabric is po ro us .

A piece o f o iled s ilk pro te ctive is applied next the skin , then a c o n

siderab le quantity o f the gauze is taken and fo lded into abo ut eightlayers and placed o ver the pro tective. In o rder to c ompel the dis

196 RE PORT ON SURGERY .

draws a comparison between the results Observed from 1860 to 1867 ,when , under Billro th , the o pen treatment was but rarely fo llowed, andtho se met with in 1868- 1872 , when ,

under Ro se, this plan was fo llowedalmo st without exception . There were no alterations o f any impo rtancein the building o r o ther arrangements o f the ho spital during the time .

Kronlein first gives a h isto ry o f the subjec t . In 1856, Vezin , o f

O snaburgh , des cribed, in the Deutsche results Of thirtyamputation s which he and Barts cher had perfo rmed in the c ourse o f

twenty-one years , and o f wh ich o nly three had pro ved fatal . In 1859 ,Burow

,o fKOnigsberg, stated that he had had o nly three deaths in 6 2

c ases Of amputation . Vezin and Bartscher applied no kind o f mean s

fo r uniting the wo unds while Burow used sutures half an ho ur after

the Operation ,tying them ,

however,in such a way that they c ould be

readily lo o sened in case o f distens ion . In all o ther respec ts the wo undswere left without dres s ing. In 1866, Burow had increased the numbero f his cases to 94, still with on ly three deaths . In 1867 , Pas savantstated that he had fo llowed the metho d in c ases o f resectio n it was a lsoadopted by Billro th and E smarch

,while Stromeyer

,Pirogo ff, and

Lucke,spoke with m o re reserve o f its value . Ro se

’ s plan agrees withthat o f Bartscher and Vezin he does no t attempt to o btain healing bythe first intention

,but regards careful arrest o f haem o rrhage, and as

perfect rest as po ssible, as c onditions necessary fo r succes s

In the statistical portion o f his essay Kro nlein gives the c omparativeresults o btained in the larger amputation s , extirpation o f the breast,and the c onservative treatment o f c omplicated frac tures . During the

years 1860— 1867 there were 140 amputations , o fwhich 72 , o r 5 14 percent .

,were fatal from 1867

— 187 1 there were 85 , with a mo rtality o f°

1 7, o r‘

2 0 per cent . Neither the place o f the amputation nor its

cause, the age o r sex o f the patient , o r the mode o f Operating, pro ducedany essentia l differenc es

,and KrOnl ein thence c onc ludes that the

impro ved results can only b e attributed to the after-treatment . In s ix

cases healing to o k place w itho ut any fever. Of extirpation o f the

breast there were, in the first perio d, 34 cases,with a m o rtality o f 3 2 2

per cent . and, in the s ec ond, 2 2 cases , with a m o rtality o f 136 per cent.In the first perio d, 86 cases o f c omplicated frac ture were healed c o n

servatively, Of which 2 5‘

5 per cent . died : in the sec ond, 65 cases,with

a m o rtality o f 2 1'

5 per cent. Hence Kro nlein c onc ludes that, in theZurich ho spital at least, the Open method Of treatment has pro vedsuperio r to all o thers .Some interesting statistic s are given regarding the o c currence o f

ac c idental surgical disease . In the first perio d,the pro po rtion o f deaths ,

from pyaemia and septicaemia, to the to tal number o f deaths was as 2 2 6

to 40°

3 in the sec ond, it was as 69 to 197 . On the o ther hand,the

number o f cases o f erys ipelas increased in the first perio d, there were39 c ases am ong 2 60 patients , o r 1 1

°

5 per cent while,in the second

,

there were 2 6 cases am o ng 1 72 patients, o r 15 1 per cent . This increas eOf erysipelas Kro nlein attributes to the changes o f temperature, whicho c cur in a ho sp ita l freely ventilated by natural means , as is that atZiirich ; and he suggests that it m ight be o bviated by well -regulatedartific ial ventilation .

ACUPRE SSURE . 97

Pirrie writes on this subject in the Lan cet,

’11,

his fo rmer c ommunic ation ,nearly do ub led his

e,and feeling fully c o nvin ced as to the efficacy o f ac upres sure,

ous to see it m ore generally adopted. Three m odes only are

they are now named Circumc lus ion,To rso c lusion

,and Retro

In the first metho d, a pin and a lo op o f inelastic wire are

in the o ther two,only a pin . Circumc lus ion c ons ists in enter

in the tis sues,a line o r two to one s ide Of the artery, push ing

and causing its po int to emerge a little beyo nd the ves sel ;pass ing a lo o p Of inelastic iron wire o ver the po int o f the pin ,

bringingthe wire o ver the track o f the artery and behind the stem o f the pin ,

drawing it suffic iently tight to c lo se the ves sel,which is pro ved by the

arres t o f the haem orrhage, and fixing it by a s ingle twist aroun d thepin . The slight am ount o f direct and c ontinuous pressure required topro duc e perfect arrest Of c irculation through an artery is remarkable .

Of all metho ds o f acupressure th is is the best it is perfectly reliable,

it is m o s t generally applicable, it may b e perfo rmed in an amaz inglyshort time, and, like the o therm etho ds , in o rdinary c ircum stances without the aid Of an as sistant . When the artery is to be relieved frompres sure the head o f the pin must be gently twirled, and having beenthus lo o sened

,may be pulled out with the greatest ease witho ut caus

ing any pain ; after which, the lo o ps , being liberated, can be readilywithdrawn .

Torso c lusion is the Aberdeen metho d o r the metho d by the twist .It c onsists o f two stages . A pin is thrust into the tis sues c lo se to them outh o f a ves sel, pushed along in its direc tion fo r a sho rt distan ce ;then, sec ondly

,a quarter turn is given to the pin, s o as to place its

emerged extrem ity, abo ve, and at right angles to the artery it is pressedwell down against the small p o rtion Of tis sue between the instrumentand the artery

,and the po int is sent, fo r some distance, into the tis sues

beyond the artery, fo r the purpo se o f securing the pin in po s ition and

o f maintaining the twist . This is the s imples t, the easiest,and the

quickest m etho d, and is perfec tly effic ient . There can b e but littlem o lecular injury o r straining o f tis sues

,and by the gentlest twirl and

trac tio n the pin can be eas ily withdrawn ,with extremely little

,if any,

disc omfort to the patient .Retro c lus ion, s o named in c onsequence Of the pin pas sing ultimatelybehind the artery

,is a c onvenient m o de o f securing vessels o f small

,o r

very m o derate s ize . In the first step , the pin is entered in the muscular tis sue, a little to one side o f the artery

,held alm o st flat upon the

wound, caused to emerge and pas sed in front , acro s s , and a little beyond

the track o f the artery. Only a few muscular fibres are raised upon thepin , and it is caused to emerge befo re being sent acro s s the track Of theartery . In the second step , the head o f the pin is made to des cribe thegreater part o f a semic irc le

,s o as to be placed nearly flat on the Oppo site

s ide o f the wound ; its po int is then sent beh ind the artery, in the c on

trary direction to that in which it pas sed in the firs t m o vement, andpressed on until it is fixed in the tissues beyond the ves sel . Figuresare given .

Experience has shown that in o rdinary circumstances where acupres

198 REPORT ON SURGE RY .

sure has been skilfully perfo rmed, vessels o f c omparatively small size ,such as the fa c ial , tem po ral, radial

,ulnar

,mammary , and spermatic ,

may be safely freed from pres sure in eight hour s an d larger arteries ,as the brachial, axillary and femo ral, in twentyf our . In one cas e a b oywho se thigh had been amputated rem o ved the pin in fo ur hours

,from

the femo ral,without any haem o rrhage resulting . In ano ther ca se the

axillary was relieved in fifteen hours witho ut ill result. Of two tho usandarteries , a cupres sed, haem o rrhage only o c curred twice o n the remo val o fp ins , and the vessels were immediately secured again . T he result o facupressure is adhes io n o f the internal surfaces , with the fo rmatio n o f

an internal c o agulum m o re o r les s adherent to the artery . S in c eMarch , 1864, Dr. P irrie has practised acupres sure in all kinds o f Operation s witho ut failing to arrest hsem o rrhage . Ca ses are mentioned inwhich rapid un ion fo llowed in large wo unds . Dr. Pirrie has no t seen

a case o f septic po ison ing since adopting acupres sure .

Mr. Clement Lucas describes a new plan . He uses an o rdinaryacupres sure needle , with a ring at the end o ppo s ite the po int, and a Io o po f wire . The needle , at about an inch from its po int , is twisted round

o n itself, so as to form ano ther ring. The lo op Of wire is first pas sedthrough the ring, at the end o f the needle, and then through the sec o ndring, s o that the end o f the lo op will pas s o ver the po int o f the needle .

The lo o p is then bent up o ut o f the way, and the needle and wire mayb e s o kept ready fo r use . When employed, the pin is pas sed under

the artery, as far as the sec o nd ring, the lo o p o f wire is bent do wn,o ver

the po int and then withdrawn , along the needle, till the artery is c ompres sed as tightly as des irable

,when the distal ends o f the wire are

sec ured round the needle . T o remo ve it the wire is untwisted and thepin pulled on . If bleeding o c cur, the wire is again tightened, if no t, theneedle is remo ved altogether. T he plan is easy o f ado ption , and safe

,

and is the o nly one which allows o f being reapplied, if bleeding o ccursat o nce

,witho ut Opening the stump . Figures are given. Lancet

,

Sept . 2 , 1871 ,Cases illustrating the pro ces s o f Oc c lus ion in arteries after acupres sure, w ith

its relation to th e treatm ent o f surgic al haem o rrhage and as co mpared w ith ligatureand tors ion,

are given ,by J . J . Gant Clin . So c . m

, w ith illus tratio ns .

T ors ion of arteries an d dress ing of wo unds —Mr. Callender’s expe

ricuce has been in favour o f to rsion . His first dress ing has been ,firs t

,

the leaving the surfac es to nature, after carefully arresting bleeding,and after p lac ing them in appo s itio n ; sec ondly, tho ro ugh co vering upOf the wo und with lint o r with c o tto n-wo o l . (Olin . Lec ture

,

‘Brit.

Med. Jan . 2 0 ,

Surgica l trea tment of aneurism—Mr. Ho lmes enters,in deta il

,into

the surgica l treatm ent Of aneurism , in his lec tures at the Co llege o f

Surgeon s , in June , 1872 , published in full , in the Lanc et and in thefo rm o f ab strac ts , in the o ther m edical jo urnals . Space will no t a llo wo f o ur fo llowing him in his critic al exam ination o f the c ases pub lis hed .

The main pro po s itio ns are s tated suc c inc tly by him self : 1 .That aneu

rism s , o f whatever fo rm ,and however near the heart they may be , o ught

n o t to be regarded as in curable, but s ho uld b e m ade the o bjec ts o f


m ents,in the neighbourho od, were oedematous ,

varic o se state . As ligature o r c ompres s ion apit was determ ined to try the plan o f injecting ergo tin sa s rec omm ended by Langenbeck . The s o lution ,

used,drachm o f Bonjean

’

s ergo tin , and three drachm s , eac h , 0

alc o ho l . Of th is,a portion ,

c ontaining half a grain o f

ally in creased to three grains , was injec ted in the neighbourho od o f the

swelling, at first every sec ond day, afterwards every third day. Altogether fifteen injection s were made between “

O ctober 2 5th and

December 1st . A dim inution o f the tumo ur was first no ticed after the

fourth injection ,and after this c ontinued steadily . The injec tions pro

duced Sharp pain, lasting fo r about two hours , but no t fo llowed byabs ces s . At the p o ints o f injection ,

however,there was left s ome in

duration o f the skin and subcutaneous tis sue,which c ompressed the

veins and, probably, had a sim ilar cfiect o n the aneurism . In the

beginning o f December, the suprac lavicular fo s sa was free from the

tum our ; digital c ompression was now applied during three h ours,in

the m o rn ing and three, in the afterno on,fo r six days ; under this treat

m ent the tum our to tal ly disappeared. As a precautionary m easure,

ten injec tio ns c ontaining, each , three grains o f ergo tin were adm inisteredat long intervals, and c ompress ion ,

with a bandage and pad, was keptup fo r some time . The aneurism ,

when the patient was last seen (Jul y,was quite cured

,fo rm ing a hardened mass attached to the

sternum and c lavic le .

Mus cular sp asm relieved by compress ion of arteries .

—M . Bro ca havingfo und

,in his own person ,

that c ompres sion o f the fem o ral artery relievedcram p o f the leg, c onceived the idea o f applying the same treatmentto c onstan t

,vio lent, mus cular c o ntrac tio n in a ca se o f frac tured leg

which came under his care . The spasm s were s o vio lent and painfulthat the l imb c ould no t be put up in splints . On applying pres sureto the femo ral artery the c ontrac tions at o nce ceased ; and on theirrecurring, at a later time

,when the dres s ings were being readjusted

,

c ompres s ion was again applied suc ces sfully . (‘Journal de Med. et

Chir. March,

Aneur ism of the common c aro tid arterg ; ligatur e—A man

, set. 39 ,c ame under the care o f Mr. James Lane o n ac co unt o f a large , pulsating tumour o n the right s ide o f the neck

,o f nine m o nths ’ duratio n .

T he artery was ligatured abo ut two inches abo ve the s terno -c lavicularjo int with a silk ligature . Increase o f temperature was no ted

,o n the

s ame s ide,fo r the first two days . T he temperature then sank to the

no rmal,and

,finally, below that Of the Oppo s ite s ide . T he man pre

sented h im self fo r examination eleven weeks after the Operation ,and

scarcely any trace o f the tum our c o uld be dis c o vered. Lancet, ’ O ct.

Mr. G amgee narrates a case in which he ligatured the left c omm on

c aro tid artery,below the om o -hyo id, fo r aneurism . The patient died

s ix days later. It was found that he had a cancer o f the rec tum whichhad ul cerated into the peritoneum and set up peritonitis . T he c ondition o f the wound and o f the aneurism had been very satisfac to ry .

Lancet, ’ June 3 , 187 1 ,

ANEURl SM—LIGATURE OF ARTERIE S . 201

Aneur ism of the innominate—app arent cur e—A c ase in whichnom inate was diagno sed, and in which a cure appa

is reco rded by Mr. Mo rgan . Ice was app lied and sul

digitalis (three dro ps o f the tincture twice daily)The treatment was c ontinued about a month . T he

c cupation , having been quite unable to do s o befo re .

apparently, quite cured at the time o f the last n o te,o f eighteen m onths . (‘Dub . Quart . J Feb . 187 1 ,

A case o f axilla-subc lavian aneurism was treated by digital pressureon the cardiac side . Slough ing o f the skin and deep tis sues o c curred

around the sac . U ltimately a partial cure resulted. The patient wa sa man

,set. 45 , under the care o f Mr. Gay . Lancet,’ Feb . 10

,1872 ,

18

Anewrism of the as cending p ortion and arch of the aorta,treated by

liga ture of the left caro tid artery .—Aman , set. 48, a farm labourer, came

under the care o fDr. Co ckle for an aneurism o f the arch o f the ao rta .

The symptom s are given in detail . The left c aro tid artery was ligatured abo ve the om o -hyo id byMr. Heath . T he wo und healed quickly .

The symptoms , o f tum our press ing fo rward the sterno - c lavicular articu

lation and bulging into the neck, of impuls e, o f inequality o f the pup ils ,&c . , dim ini shed o r disappeared. At the end o f four m onths he had c on

tinued to impro ve, and walked fourteen m iles in one day. He was

shown at the Co llege o f Surgeons , and his case was c ommented on byMr. Ho lmes . (See Lancet

,

’ July,1872 Clin . So c . v

,

18

Subc lavian anewrism temp orary c omp ression of innominate arterg 6gelas tic comp ress or sp ecia lly c ontrived ulcera tion of ves sel antisep tic

ligatwre s ec ondarg hwmorrhage on fifth and s ixth da/gs dea th .

—Mr .

Bickersteth c ommunicated the case to the Med -Chin So c .,No v. 2 6,

1872 . (Abstrac ts Med. JLiga ture of the subc lavian artery .

- Sir W . Fergusson ligatured thesubclavian artery fo r axill ary aneurism (‘Med . Times and Feb . 2 5 ,187 1 , and Brit Med. March 4 , He found the omo

hyo id a go od guide . The patient died. A sec o nd case is also rep ortedMed. Times and April 2 2 , 187 1 , T he an eurism was

traumatic . A healthy young man was wo unded, five o r six weeks before,with the pro ngs o f a pitchfork , o ne o f which entered at the anterio rmargin o f the delto id mus c le, and pro bably damaged the axillary artery .

The wound healed, b ut s o on afterwards a pulsating swelling was no ticedin the arm pit. When adm itted,

there was a tum our, the size o f an

o range , high in the axilla . SirW . Fergus son remarked that he wouldhave been justified

,as it was a c ase Of wounded ves sel

,in c utting down

and tying the artery abo ve and below ; b ut there are exceptio n s to thebest surgical rules . T he wound would be extens ive ; the vein m ightalso be affected ; there m ight be great haem orrhage ; c ompres sion o f

the subc lavian is a doubtful safeguard. An o bjection to the pro ximalligature m ight b e found in the c o llateral c irculatio n .

” This o bjec tion ,

however,though abundantly pro ved as regards the brachial artery, has

never yet been established as regards the axillary .

202 REPORT ON SURGERY .

Mr . G ay tied the right subc lavian

c o urse, fo r an aneurism invo lving theT he patient died, on the n ineteenth do f the parts at the seat o f the o peration was quite satisfac to ry .

Lancet,

’ May 6 , 187 1 , 6 1 1 als o Path . xxii,Liga ture of the c aro tid and subc lavian arteries—In a ca se o f aneurism

a t the ro o t of the neck,Mr . James Lane ligatured,

the caro tid and sub

c lavian arteries . The pa tient , a woman ,set . 40 , rec o vered. S om e tem

po rary impro vem ent fo llowed ; but ultim ately the aneurism s teadi lyin crea sed in s ize

,the sternum and c lavic le becom ing ero ded. Lan cet , ’

Jan . 13 , 1 782 ,Aneurism (f the arch of the aorta s imula ting innomin a te aneurism

a ttemp ted dis ta l op era tion—Mr. Heath intended to ligature the s ub

c lavian and caro tid arteries,but, in attempting the fo rm er, fo und the

s ac (o f what pro ved to be an ao rtic aneurism ) in the way and des isted .

Remarks are made on the bearing o f the c a se o n dis tal ligature . T he

patient was in a dangero us state , and m ight have died fro m burstingo f the sac at any time . Pro bably the Operatio n has tened his death .

There would have been no difliculty in ligaturing the common caro tid

arterg, and it is an interesting speculatio n as to the influence this,alo ne

,

wo uld have on the result . T he left subc lavian was o bstruc ted. Path .

xxii, 9

Trauma tic axillary aneurism ; ligature of the subc lavian ; recovery .—Dr.

C . C . F . Gay rec o rds the c ase o f a man,set . 2 6

,who had been wounded,

six years previo us ly , by a pisto l-ball,in the fro nt o f the left sho ulder.

S o on afterwards a tumo ur was no ticed in the armp it. The ball wasnever remo ved. A tumour, as large as a child’

s head, projec ted infro nt Of the axilla on the chest . It seemed like a large a bs ces s abo utto burst . NO bruit c o uld be detec ted, no r any pulsation . The arm was

paralysed, and there was no radial pulse . A needle,thrust in

, gave exitto a few drops o f blo o d. A tro car gave exit to a little blo o d. An ia

c ision was m ade down to a blue surface,and then pres sure with the

handle Of the s c alpel burst the sac,and blo o d spurted o ut pro fus ely . A

free Open ing was then m ade into the sac and c om pres s io n made withthe finger o f an ass is tant

,while the third part o f the subc lavian was

tied. On the seventh day there was sec o ndary haem o rrhage , whic hs to ppedwith pres sure . The paralys is o f the arm was dis appearing, b utthe radial pulse had no t returned when last seen . Am . Jo urn . Med.

S c iences,

’

O c t . 187 1 ,Trauma tic aneurism the vertebra l a rtery .

-Dr. Ko cher, o f Bern ,

relates , in Langen beck’

s Archiv fiirKlin . Chirurg.

’

(xii, the cas e

o f a m an named Abraham S set. 48, who , three weeks befo re hisadm is s ion into ho spital , o n Oc to ber 2 7, 1868, had rec eived three s tabsin the nape o f the neck and o ne o ver the s c apula . The latter wo undand two o f the o thers s o on healed ; but the fourth had remained open ,

and from it there had been daily haemo rrhage , o ften pro fuse . This wasrestrained by plugs so aked in s typtic s o lutio ns

,o ver which was laid a

c ompres s o f c harpie m o istened with s o lutio n o f perchlo ride o f iro n,the

who le being c o vered by a bandage . On rem o ving these dressingsthere was seen

,about an '

inch to the left o f the sp ine, at the level o f


have terminated in rec o verbelow the o c c ipital bone on

either the o c c ip ital o r the

arrested by pres sure on the

uncertain whether the vertebral o rbut the haem o rrhage, on the rem o v

intro duc ing the finger as far as the transverse pro cesses o f the vertebrae,so on rendered the diagno s is c lear.

In a number o f c ases , traumatic aneurism o f the vertebral artery hasbeen suppo sed to be seated in one o f the branches o f the caro tid.

Ko cher adopts Barb ieri’s explanation o f this . It is that,when the

c aro tid is c ompres sed again st the s o -called caro tid tuberc le , o n the

transverse pro ces s o f the S ixth c ervical vertebra,the vertebral artery is

als o c ompres sed, at its p o int o f entry into the fo ramen Of the transversepro ces s . The deception is n o t remo ved by c ompres s ing the caro tid at

a higher po int, fo r the vertebral may pas s up in fro nt o f the tran sversepro cesses . If it b e desired to c ompres s the vertebral alo ne , the planrec ommended by Barbieri must b e fo llowed, o f applying deep pressure,from without inwards , at the inner edge o f the s ternO-masto id musc le .

Ko cher says that c ompress ion o f the vertebral with the caro tid may be

avo ided by applying pressure to the latter, laterally, through the stern o

m asto id musc le . In n ine o f the rec o rded cases the wound was at,o r

abo ve,the sec ond cervical vertebra ; in two , it is stated, merely, to have

been at the upper part o f the neck, and, in six,it was below the sec ond

vertebra . In four o f the latter cases it was in the neighbo urho od o f the

external caro tid and its branches . Barbieri believes that the seat and

directio n o f the wo und and the s ituation o f the swelling will aid the

diagn o s is, but Ko cher dis sents from this Opin ion .

W ith regard to treatment, Ko cher, fo llowing Barbieri, s ays that inthree cases there is n o reco rd. In one case

,death wa s the result Of

haemo rrhage ; in ano ther o f c o mpres s ion o f the medulla o blongata bythe eflused blo od. Ano ther patient died o f meningitis , and ano ther o fsepticaem ia fo llowing suppuration o f the areo lar tis sue o f the neck . One

patient died o f haemo rrhage after the remo val Of a bul let . In elevencases, the caro tid artery was tied, through erro r in diagno sis , and thisOperation probably rendered the evil greater, by increas ing the pres sureo f the blo od in the vertebral artery ; indeed, in two o f the cases thuso perated o n

,the patient died o f vio lent haemo rrhage from the seat Of

injury, and, in three , from burst ing o f the aneurism . In five cases ligature Of the caro tid was fo llowed by paralys is and death . Lucke

,in a

case in which the aneurism increased rap idly after ligature Of the

c aro tid,injected chlo ride o f iro n into the sac

,and a ls o applied plugs

s aturated with the perchlo ride ; the patient, however, died with symptom s o f paralysis . Maiss o nneuve

,in a case o f gunsho t wound, tied

bo th the vertebral and the inferio r thyro id arteries, and rem o ved the

bullet . T he haem o rrhage was arrested, but death o c c urred from infil

tratio n Of pus into the spinal canal , and c o nsequent inflammation .

In MObus’

s c ase the treatment fo r the first seventeen days c on sistedin the applic ation o f bandages and c o ld lo tions . Haemorrhage then

COMPRESSION IN ABDOMINAL ANEURISM’

.

appearing, astringent s o lutions , and, later, iced c ataplasm s were used.

Two m on ths after the receipt o f the injury the patient was seized w ithsevere pain ,

during which the aneurism dim in ished,and at las t disap

peared, the patient rec o vering.

Ligature o f the vertebral artery, Ko cher o bserves,is impo s s ible ,

except in a p o rtion ,about six centimetres lo ng, between its o rigin and

its entrance into the transverse fo ramen o f the s ixth c ervica l vertebra ;and, in m o st o f the cases

,the only remedy

,in cases o f wound o f the

vessel , is the intro duction o f a plug saturated with som e dis infectingfluid and pressed deeply . If this fail

,two resources are left—the appli

cation o f styptic s and the Hunterian ligature o f the artery . The lattero peration has been twice, o n ly, perfo rmed on the living subject—on ce

by Mais sonneuve, in the c ase already referred to, and once by Smyth ,

o f New Orleans , in a case o f regurgitant haem o rrhage after ligature o f

the innom inate fo r subc lavian aneurism . Distal ligature o f the ver

tebral artery, between the o c c ipital bone and the atlas,as has been sug

gested by Dietrich, would be bo th difficult in performance and uncer

tain in result.In applying styptic s it is doubtful whether they should be intro

duced deeply . In o ne case the nerves lying behind the artery wereinjured, and in ano ther, attended with les ion o f the bones

,dangerous

inflammation o f the spinal men inges to ok place . If simple pluggingfail, the wound must be laid well o pen ,

s o that the surgeon can see the

bo ttom o f it ; and the styptic must be applied immediately and exc lusively to the bleeding o rifices o f the ves sel . The bes t s typtic is

’

the

so lution o f perchloride o f iron . It is m o s t impo rtant that the m ovements o f the head should be restrained by mean s o f a stiff cravat .

When an aneurism has fo rmed, digital c ompres sion o f the artery on

the transverse pro ces s o f the s ixth c ervical vertebra,o r injec tion o f

ergo tin ,in the neighbourho o d o f the tum our

,may be tried . Attempts

to pro duce c o agulation by elec tric ity, o r by injec ting c o agulating fluidsinto thesac , are ineffic ient and dangerous . The Hunterian Operationis uncertain in result, o n ac c ount o f the c o l lateral c irculation . The

treatment in which Ko cher has m o st c onfidence is the early laying open

o f the sac and plugging, and, when po s s ible , the direct application o f

so lution o fperchloride o f iron to the bleeding ends o f the vessel .Abdomina l aneurism cured by comp ress ion of the aorta .

—Dr.Mo xon and

Mr. Durham rec ord a case in which an abdom ina l aneurism was curedby c ompression o f the ao rta . This is the on ly case rec o rded prec is elysimilar to the one narrated by Dr.Murray . The aneurism c ould b e distinctly felt o ver a space extending from rather less than an inch below thecartil ages o f the false ribs to the level o f the umbilicus, and from the

right o f the median line to abo ut m idway between the median line and

the left border o f the abdomen , o r rather further. The patient wa skept in bed and perfec tly at rest for eleven days . Very sparing dietonly was allowed, and pill s o f acetate o f lead and o p ium were adminis

tered every six hours with the view o f diminishing the desire fo r fo o d.

The to urniquet was screwed down very s lowly until the pulsation wascompletely arrested, the patient being under the influence o f chloroform . The lower extremities were enveloped in c o tton wo o l and hot


water bo ttles placed in the b ed. T he

tained fo r ten hours and a half. It thtnnue the treatment . The aneurism no

er tha

Opium were given . After this , thea neurism was smaller

,much harder

,

been . It still pulsated in a markedw ere remarkab ly s light c ons idering thright fo o t was c o lder than the o ther. Tinc ture o f iro n and

were given in ten m inim do ses . N0 bad symptom o f anybut the pulsation o f the fem orals which had returned to

extent s o on ceased altogether. T he c onditio n o f the aneu

At the end o f a fo rtnight it was no t o nl y much smaller,feebler in pul satio n, but such pulsation as remained c o uldwith great ease, by digital p rothan a m onth the pulsation c

paper c on c ludes with remarks o n such c ases as the abo ve . Sphygmograph ic trac ings o f the pulse are given . Med -Chin l v,

D is ta l comp ress ion of the a o rta .

—Mr. Bryant reco rds a c ase in whichhe employed dista l c ompres sion o f the ao rta fo r abdominal aneurisms ituated high up . T he patient was a man set . 30 . A to urniquet wasa pplied fo r twelve hours under c hlo ro fo rm

,the tum our pulsating all the

time . Pres sure wa s dis c o ntinued fo r twelve ho urs and was then appliedfo r fo ur ho urs . The man then bec ame very ill and died eleven ho urs ,later

,thirty-nine h o urs after the firs t appl icatio n . At thep o s t-mo rtem

it was found that intestine had been damaged by pres sure and had set

up periton itis , and that the aneurism was c on s o lidated. A drawing o f

its c ondition is given . Mr. Bryant says,

“ The interest o f this ca seis very great .

” “In a c linical po int o f view,

it illustrates the fac t thatperiton itis , as a c o nsequenc e o f c o ntusio n o f the intestine o r peritoneum

,is a danger which mus t be taken into ac c ount in;the use o f the

abdo minal to urniquet . ” It dem on strates the patho logical fact thatpres sure upon the ef erent artery o f an aneurism o r distal pres sure , fo rtwelve o r s ixteen ho urs , is as c apable o f pro duc ing the fo rmation o f a

s o lid c o agulum in a s ac culated aneurism, even in a large artery

,as pres

sure upo n the afi'

erent ves sel,o r proximal pres sure . The c ase suggests

inquiry into the value o f c ompres s io n by o ther mean s than that Of a

tourniquet. I would also suggest that s o me instrumental means shouldb e lo oked fo r by whic h the inner and m iddle c o ats o f an artery m ay be

divided and allo wed to recurve,a s in to rs io n

,without destroying the ex

ternal c o at, ac ting on the knowledge that an artery after a c o ntus io nm ay bec om e o c c luded

,and the fac t Mo o re has given us that a blow upon

the c omm on iliac artery m ay s o detach its inner c o ats as to allow themt o recurve and thus c lo se the ves sel . ”Mr. Bryant Speaks favo rably o f Dr. Spiers ’ artery c onstric to r s o

far as he has tried it on the dead subjec t.The distal treatment o f an aneurism is well wo rthy o f renewed


this o peration for femo ral aneurism Med. Times and Feb . 2 5 ,187 1 , A suc ces sful case under the c are o fM r. Jes so p is no tedin the Lancet, ’ O ct . 1 2

,1872 . A suc ces sful case fo r ingu inal aneurism

is no ted under the c are o f Dr. Bernard June 2 2 , 1872 , 85G angrene o f the to es fo llowed. A catgut ligature was used.

Femo ro -

p op litea l aneurism trea ted by temp orary deligation of the

femora l artery, &c . bul let in head of tibia—M r. Stokes rec o rds thec ase o f a man

,set . 36, adm itted Aug. 1 7 , into the Richm ond

Ho spital, suffering from a large pulsating tum o ur, o ccupying the lowerextrem ity o f the thigh and po pliteal space . He had been a so ldier, andin 1860 received a gunsho t wo und near the knee . The ball entered a

little external to the tubero sity o f the tibia, and was never extrac ted.

Four years later he left the service, and up to the time o f his admis s io nwas employed as an agricultural labourer. Three weeks previously,when go ing home after a day ’ s wo rk

,he felt something jump in his

ham ,

”and then he first Observed the tum our. Pres sure was app lied

to the femo ral, but it c ould n o t be hom e . On Sept . 3 , Mr . Sto kes

expo sed the fem o ral artery, placed a silver wire round the vessel , andpas sed Po rter

’

s c lamp down on the two free ends o f the wire . Thesewere tightlyfixed to the ring o fthe c lamp —(SeeprecedingThis effectually arrested all c irculatio n through the aneurism . Fiftyhours afterwards the ligature was remo ved

,and to Mr. Stokes ’ disap

po intment there was a return o f pulsation in the aneurism . The tumo ur

then c ommenced to enl arge rapidly . Digital c ompres s ion was carefullytried fo r twenty-four hours . The thigh was then amputated by thec ircular metho d. Pyaemia set in

,and the patient gradually sank . On

exam ining the tumour the aneurism was fo und to b e a diffused one .

T he artery (pop liteal) was ruptured o n its anterio r aspect . A largem ass o f c o agulated blo o d wa s fo und in the aneurism . T he knee-jo intc ontained about an o unce o f amber- co loured serum

, o therw ise the

articulatio n was quite healthy . T he po s terio r surface o f the femur at

its lower third wa s denuded o f perio steum and slightly ero ded . Asec tion o f the head o f the tibia revealed a bullet which had beenencysted fo r ten years . An exam ination o f the po rtion o f the arterywhere the tempo rary ligature had been applied sho wed that no damagehad been sustained by the artery . This i s a m atter o f c onsiderab leimportance , a s it shows c onc lus ively that the wire c ompres so r can b e

applied to a large artery s o as to c omp letely o c c lude it fo r s o long a

perio d as fifty hours,witho ut do ing any injury to it whatever. Mr.

Ho lmes , in his adm irable lec tures at the Co llege o f Surgeons o n the

surgical treatment o f aneurism ,in speaking o f the case where I applied

the temporary ligature to the abdom inal ao rta, o bserves that the tim e

(twelve hours) during which it was app lied hardly allows a judgment

as to the ac ti o n o f the c ompressor .

’

In the fo rego ing case, however,the instrument was applied fo r fifty ho urs without there being anydam age whatever sustained by the vessel . ” Dub l . Journ . Med.

Dec . 1872 ,

Femora l aneurism c omp ression cure—U nder the care o fMr. Jes s op .

Lancet,

’

N o v . 2,

Fusiform femo ra l aneurism cured by c omp res sion .—Mr . Spence nar

POPLITEAL ANE URISM . 209

f a man, set . 3 2 , in whom c ompression o f the femoral

aneurism . He remarks on the nature o f the aneurism,

for ado pting the partic ular m o de o f cure . Watson ’

s

in the lowero ther case, an

he femo ral .the femora l

and, as

a direct,

as a

Mr .

Spence had determined, if c ompress ion failed, to cut down on the arteryin Hunter’s canal . The exact time which elap sed before pulsatio nceased is no t no ted, but it was the even ing o f the first day . Mr .

Spence lays stress o n c omplete c ompression . Med. Times andJune 1 ,

Death from s econdary haemorrhage after the use of a carbo lised catgut

ligature—Mr. Ho lden rec ords a case in which he ligatured the femo ral

with a catgut ligature, and in which sec ondary haem o rrhage o ccurred

on the ninth day, and pro ved fatal almo st imm ediately. At the p o stmortem

,a large c o llection o f pus was fo und burrowing in the thigh .

At the po int where the vessel was tied, there was a small, jagged perforation o f the arterial co ats . No trace o f the ligature c ou ld b e found.

St. Barth . Ho sp . viii,P op litea l aneurism ligature of thefemora l artery

—Two cases, under

the care o f Mr. Savory, are recorded in the Lancet, ’ Aug. 5 , 187 1 ,19 1 . The patients reco vered.

A case Of po pliteal aneurism ,bursting into the knee-jo int and sup

po sed to be syn o vitis o f the jo int , is narrated in the Lancet , June 2 4,1871 , 85 1 , by Mr. Jamies on ,

o f Shanghai .Mr. Lister mentions (Address, Brit . Med. Aug . 2 6

, 2 87 1 ,two cases o f diffused, po pliteal aneurism treated by ligature o f the

femo ral with catgut, antiseptically . Bo th patients rec o vered. In o ne

case,the ligature was applied in a fo rbidden region , from the vic inity

o f the profunda o r o ther considerable bran ches . ”Mr. Co oper Forster and Mr. Barwell relate cases o f cure by c om

press ion . Clin . So c . v , 105 andMr. Ho lmes records a case which was cured by vo luntary flexion o f

the leg in about thirtysix ho urs . Brit. Med. J April 6,

1872 .

Mr

). Stokes figures an in strum ent for arterial c ompres sion (P res se

artere) , devised by Mr. O’

Beilly, and gives a narrative o f a case inwhich he used it . The pressure was kept up ,

night and day, for fourdays, witho ut causing any inconven ience or pain . (

‘Dub . Journ . o f

Med. Dec . 1872 ,Two cases are rec o rded by Mr . Ho lden, o ne o f which was cured bypressure and the o ther by genuflexion . After thirty hours ’ c ontinuo uspressure (digital) , aided by a bag o f sho t placed o ver the fingers, whichenabled each person to pres s fo r two hours, pulsation quite ceased.

Mr. Ho lden thinks it ought then to have been c ontinued fo r a while,141


fo r the pulsation again returned at the end Of twenty-fo ur hours , andthey had to press fo r s om e time longer. In the sec o nd c ase s impleflexion was tried. On the seventh day very l ittle pulsation remained ,and the pres sure o f a tourn iquet wa s added o ver the fem o ra l . At theend o f ano ther week the pres sure was gradually rem o ved. In six weeksfrom the beginn ing o f the treatment the patient was allowed to walkabo ut . St. Barth . Ho sp . viii ,A c ase o f aneurism o f bo th po pliteal arteries treated suc c es sfull y by

c ompres s ion o fthe fem o rals is no tedby Dr. Rendle . St . Barth . HOSp .

viii,

Aneurism,fa lse—Mr. Spence narrates some interesting cases o ffalse

aneurism . A m an c ame under his care fo r the results o f a stab in theupper and inner part o f the calf o f the left leg, inflicted ac c identally sixweeks previously . Haemo rrhage had o ccurred repeatedly . Pres sure

on the fem oral did no t check veno us haemo rrhage . Mr. Spen ce feltc onvinced that the p o sterio r tibial artery and vein were wo unded. He

made an inc is ion,about eight inches long, along the inner aspec t o f the

ca lf, dividing the gastro cnemius and s o lens m us c les and expo sed the

ves sels . It was seen that the po sterio r tibial artery wa s inj ured c lo seto the bifurcation o f the p opliteal, and als o o ne o f the vense c om ites .A ligature was applied abo ve and below the wo und in each vessel , andano ther was applied to the anterior tibial

,just below the bifurcation o f

the po pliteal : The ligatures were left hanging out,and wet lint ap

plied to wound. The patient rec overed, and resumed wo rk as a po stm an in a c o untry district . Mr. Spen ce remarks on the po ints o f

interest in the case. The patient was in a very unfavo rable c onditio n,

the limb greatly swo llen . The Operation practically amo unted to ligaturing the lower part Of the p o pliteal a s well as a large vein , yet re

c o very fo llowed. He als o details a case o ffa lse aneurism of the radia l .

The hmmo rrhage at the time o f the wound was c ontro lled by a pad, &c .

,

and the wound healed ; nevertheles s an aneurism fo rmed subsequently,which had every appearance o f being an acute absces s . Med. Timesand June 2 9 ,

Ligature of artery abo ve elbow, fo r aneurism below the bend of the

elbow.

—In this case there was a high divis ion . The aneurism had re

sulted from a spra in, and invo lved o nly the radial,s o this was tied by

Mr. Ha lke above the elbo w. Compress ion and flexion had failed .

Med. Times and April 1 , 187 1 ,T ourniquet.

—Mr . Bulley has devised a double tourniquet fo r c om

pres sing the fem o ral,alternately

,in one o f two po sitions , without shift

ing the instrument . Two pads with s crews are fixed to a bar, c onnectedby rings at each end to a long pad, which is p laced behind the limb .

The relative p o s ition o f the s crews in front can be altered. Med.

Times and Jan . 2 7, 1872 ,Congenita l lymphatic o arix (s ee previous Bien .

—Dr. Patersondescribes a case . The child wa s a female . The who le right lower extremity was much enlarged, and lo o ked much like a leg severely affec tedwith varices in the adult . The child c o uldm o ve the limb . A quan tity o ffluid transuded thro ugh the skin c o ntinuously . About the fifth day largeblebs appeared . Death to ok place o n the n inth day after birth . The


A suc cessful case, fo r c ancero us disease, is rec orded by Dr. Bramwell .The patient died, however, five months later . Reference is made to

o ther cases . E din . Med. J No v.

A suc ces sful case, fo r o steo - sarc oma recurring ln the femur, 18 rec o rded

by Mr . Cro ft . Path . xxiii ,Reamp utation at the hip

—George A . O tis reco rds in detail a suc ces sful case Am . Journ . Med . Sc iences

,

’Jan . 187 1 , He alludes to

the c omparative safety o f exarticulating the femur,fo r diseased c ondi

tions suc ceeding a previous amputatio n in the c ontinuity o f the thigh .

He enumerates twenty-one c ases , n ine belonging to m ilitary and

twelve to c ivil surgery . This distinc tion is valueles s , as the causes

fo r o peration are strictly analogous . In twelve cases , the o perationwas done for chro n ic o steo -myelitis , in six

,fo r recurren ce o f tum ours

,

&c . , and, in three, it was c ompulsory on ac c o unt o f haem orrhage o r gan

grene . Fo urteen , o f the twenty-one (66 per cent ) , were suc ces sful .W e may c onc lude, therefo re, that in incurable diso rders o fth igh- stumps ,resul ting either from injury or diseas e, disarticulation at the hip is theproper remedy . By using a gutta

—p ercha artificia l s tump , nine o r ten

inches in length , firm ly strapped to the pelvis by a bro ad cham o is -linedcanvas band, an o rdinary artifi c ial limb fo r thigh-stumps can be used.

Sup ra- conch/loid amp uta tion of the thigh .

—Mr . Stokes writes furthero n this subject . He has found the o peration a suc ces s ful o ne, and quo tesc ases

,no ted by o thers, since his c ommun ication to the Med -Chir. So c .

(see last (‘Dub . Journ . Med. Dec . 1872 ,

Amp uta tion through thefemora l condyles—Mr. Richardson gives twoc ases (suc cessful) . In one he rem o ved the patella , in the o ther he leftit

,having rem o ved the cartilage. He divides the rec tus . In the latter

c ase the patella united well . Two o ther c ases are mentioned (suc ces sful) , under the care o fMr. Mo rgan . Dub . Quart . J 1871 ,Amp uta tion a t the knee-j oint —In a c linica l lec ture o n a cas e o f

fibro -

plas tic tum our o f the leg, in which he perfo rmed amputation a t

the knee-j o int, Mr. E richsen makes some remarks on this o peration .

He prefers a long anterio r flap , slightly rounded at the edges , and leavesthe patella . If the latter is remo ved the flap is liable to be to o thin tolive, and if it is left, there is a liability to suppuration in the largesyno vial pouch un der the quadric eps extenso r. He leaves the cartila

ginous surfaces o fthe femur and pa tella . Lancet,’ Sept . 30 , 187 1 ,Dr. Staples rec o rds two cases in which he perfo rmed amputationthro ugh the knee-jo int . One patient was a man

,set. 4 1 . T he Opera

tion was perfo rmed fo r inflammation o f the leg. A sem ilunar inc is ionwas made in front

,an in ch o r an inch and a half below the tuberc le o f

the tibia . The flap was dis sec ted up far eno ugh to reach the j o int,which was then cut through , the limb being flexed, and a sho rt posterio r flap made . T he patella filled the space between the co ndyles well .The progress o f the case was go o d. The inn er c ondyle was expo sed fo ra time, but so on became c o vered. In eight weeks he c oul d hear hiswho le weight on the stump . In five m onths he went to wo rk in a bo o tsto re, and had to stand c onstantly upon his feet ” all day. T he o therpatient was a b oy, twelve years o ld,

suffering from necro s is o f tibia, &c .

A Similar operation was performed, and a“ button of cartilage was

RE SE OTION o r SHOULDE R AND ELBOW OF THE SAME ARM . 213

taken from the internal c ondyle . In three m onths he c oul d hear hisentire weight o n the stump . He was a strum o us lad. The patella keptin go o d p o s ition . Amer . Journ . Med . Sc iences ,’ Jan . 1872 ,S enile gangrene

—Mr. Liston rec ommends amp utation under antiseptic dres s ings . Brit . Med. Aug. 2 6,Gangrene of the leg ; amp uta tion ; rec overy

—Mr. Morgan rec o rds the

case o f an Old m an who se fo o t became gangrenous , and who se leg heamputated as high up as po ss ible . The patient rec o vered. The boneso f the fo o t were found diso rganized. A figure o f the c ondition is given ,

(‘Dnb . Quart . Feb . 187 1 ,Sp ontaneous gangrene of bo thfeet, in a boy ,

a risingfrom diseas e of theheart double amp utation ; recoveryfrom op era tions ; deathfrom cardiac

andp ulmonary c onditions—Mr. Gant . Clin . So c . v,

Amputa tions .

-Favo rable results,in c ountry practice, are rec o rded

by Dr. Benny . (‘E din . Med. No v.

Amputa tion of thefo ot—Mr. Sto kes writes on Pro f. Smith ’s m odifica

tion o f Hey’ s o peration on the fo o t . The great advantage o f it is thatthe ball o f the great to e and the base o f the fifth metatarsal bone are

preserved. The Operation is performed by making an oblique inc isiona cro ss the four lesser metatarsa l bones , c ommenc ing about three quarters o f an inch in fro nt Of the base o f the fifth m etatarsal bone

,and in

a direction towards the metatarso -

phalangeal articulatio n o f the greatto e . T he inc is io n should be made down to the bones, and ano ther inc ision sho uld then b e made at the centre o f the first one

,but at right

angles to it, upwards and inwards , fo r about an inch o r an inch and a

quarter. The flaps at each s ide o f this inc is ion shoul d then be dissected o ff the bones

,and these, thus freely expo sed

,should then b e

o bliquely divided, c lo se to their pro ximate articulations,with a small

saw o r fine fo rceps . The flap should be taken altogether from the so leo f the fo o t . The operation appears to b e best adapted fo r cases o f

c aries o f the phalanges and distal extrem ities o f the m etatarsal b ones ,fOr severe injuries o f the phalanges with extens ive laceration o fthe so ft

tissues , and ep ithelial ulcerations no t unfrequently o c curring in thiss ituation . Mr. Stokes records the c ase o f a woman

,set. 58, suffering

from epithelioma o f the three lesser to es o f the right fo o t. A lithographo f the state o f the stump after reco very, and a wo o dcut o f the c ast o f

the stump o f the patient, on whom Pro f. Sm ith firs t Operated, are givenDub . Jo urn . Med . Sci,

’

Dec . 1872 ,Anhley

'

o int amp utations—Dr. Sm ith c onc ludes that ankle-jo int am

putation s are o n ly half as fata l as leg amputations , and the stump s are

better adapted bo th fo r unas sisted lo c om o tion and fo r the use o f artifi

c is l supports . In referen ce to Pirogo ff’s and Syme’

s amputations , Dr.

Sm ith is o f Op inion that the former yields the better stump for unas sistedprogressio n ,

and the latter for the adaptation o fmechanic a l aids . Sur

gical Mem o irs o f theWar o f the Rebellion ,

”

published for theU . S . San itary Comm is s ion reviewed in ‘Am . Journ . M ed. O ct . 187 1 ,R esec tion of the shoulder and elbow-j oints of the same arm—Mr .

MacCo rm ac rec o rds the case of a Fren ch s o ldier who was disabled at

the battle o f Sedan by a shell explo s ion . T he fragm ents severely lacerated the bones and so ft parts o f his right arm ,

in the region o f the


shoulder and elbow-j o ints . Fo r twelve days he did no t receive anyspec ial attention . When Mr. MacCo rmac first saw the patient, hefound a large , suppurating wound in the delto id regio n, and ano ther o n

the po sterior aspec t o f the elbow-jo int . The s o ft parts were extens ivelyinjured and the bones much c omm inuted. It almo s t seemed as if am

putation at the shoulder-jo int were indispensable . It was , nevertheles s ,determ ined, if practicable, to save the limb . The man bo re the firstpart o f the operation without an anaesthetic , but he was induced to takechlo roform f or the sec ond stage o f it . The o riginal wounds were en

larged. The shoulder-jo int was first attacked. Fo ur inches of theupper extrem ity o f the humerus were remo ved, the bone being sawnthrough at the lim it o f the fractured po rtion . The elbow-jo int was thenexam ined. Only the external c ondyle o f the humerus was implicated,and only the thinnest p o ssible slice was remo ved by the saw . The

u lna was extensively fractured, the Olecranon pro ces s pul verised, andthe shaft split throughout its upper third. The fragments were rem ovedsubperio steally, and the irregular extrem ity o f the shaft c ut through atthe junction o f the m iddle and upper third. A further portion o f the

shaft,split Off for an inch farther down the po sterio r surfac e, was als o

rem o ved, s o that the divided extrem ity o f the ulna only presented abouttwo thirds o f the sec tion o f the bone. As the radius was n o t im pli

c ated beyo nd its articulating head, this , only, was remo ved. The bones o fthe forearm were

,therefo re, divided at very differen t levels ; but the

tuberc le o f the radius was preserved with the mus cular attachmentsbelo nging to it, and the preserved perio steum was trusted to regenerate ,in part

,the portions o f ulna rem o ved. T o have sawn o ff bo th bones at

the lower level would m o st certainl y have prec luded al l hope o f a usefulresult . The after treatment c ons isted in suppo rting the injured arm

o n p illows , and pro viding fo r the free outflow o f matter.

“ Neither inthis no r in any o ther c ase o f resec tion o f the elbow o r o f the shoulderj o ints did I employ splints

,and from cho ice I always employed a single

straight inc is ion in the s oft parts . ” The patient did well fo r a week ,then symptom s threatening pyaemia set in ; an absc ess , however, fo rmed,and was o pened, and he then steadily reco vered. A pho to graph o f hisc ondition , eighteen months after the Operation ,

is given The elbowjo int is thoroughly healed, and the ulna s o far repro duced that there isscarcely any apprec iable defo rm ity o r lo ss o f shape in the j o int . He

c an flex and extend it, and also pronate and supinate the fo rearm . The

power o f the hand is being rapidl y and completely regained. As theshoulder-jo int is no t yet healed, its c o ndition 1s no t s o satisfacto ry but

by means o f the pec to ralis and latiss imus do rsi musc les he m o ves thejo int freely backward and forward. He canno t raise the arm very highfrom the side, but this is no unc omm on resul t after exc is ion o f thisarticulation , and in this particul ar instance the greater po rtion o f the

delto id musc le was destroyed by the shell fragment caus ing the o riginalw ound. I can entertain no doubt that

,as so on as the necro sed ieee o f

humerus is removed,the sinus in the region o f the Sho ul der wi I c lo se,

and the usefulnes s and power o f the limb become greatly increased.

Meanwhile, I submit that the man’s present c ondition is extremely

satisfactory ; and, while it affords an ample justification o f the operation ,


On the o ther hand, any nebeen produced, in the formends above their diseasedShould n o t be inc luded inrec o veries , o ut o f 1 19 cases , the majority (minus 15 amputation cases )had useful limb s , a s pro ved by the patient being able to resume hiso rdinary avo cations . Injury o f the ulnar nerve—an o c cas ional ac c identduring the o peration— is fo llowed by lo ss o f sensation in the littlefinger and adjo ining side o f the ring finger, with , perhaps, lo ss o f

m o tion and wasting o f the musc les ; but the sense o f touch will probably return and the o ther il l c onsequences cease, apparently by re

unio n Of the wounded nerve . This acc ident, judging from the digitalparalys is , happened, apparently, in one o f his o wn cases b ut the

tom s pas sed Off entirely, as the functional use o f the finger showthe patient was a seam stres s . Re-excision may b e prac tised—as in the

knee—when necessary, rather than amputation ,and even a third

attempt, it is said, has been fo llowed by a go od result . Of 197 cases o freco very, only in three, is it no ted that re-exc i's ion was practised. O f

five cases , underMr. Gant’s care,he had to re-exc ise in one, with a go o d

result . Secondary amputation—O f one c o llection o f 104 cases o f rec o very,fifteen underwent amputation subsequently . Of ano ther 197 rec o veries ,three, only, were subjected to amputation ,

with one fatal is sue. (Ibid. ,

August 2 6, 187 1 ,Mr. Maunder, in the co urse o f some remarks o n primary exc ision o f

the elbow-jo int (ibid.,May 2 0

,187 1 , pro po ses a m odification in

the plan o f perfo rm ing the o peration . Hitherto,when the H o r F in

c ision has been adopted, the transverse o r the sem i-transverse out has

severed tho se very structures—the tendino us pro longatio ns o f the

triceps to the fasc ia o f the fo rearm—by which , as Mr . Maunder has

demonstrated bo th o n the living and the dead subject , extension by thetriceps muscle may be a lways secured. The integument having hdivided, the triceps mus c le just abo ve the O lecranon should be cut

longitudinally. The inner po rtion is to be detached from the end o f

the o lecranon,and it, with the ulnar nerve and soft parts along the

inner side o f the bone-ends , are to be separated from the bones . The

o uter half o f the severed musc le is to be cut transversely, but is to bescrupulously preserved c ontinuous with its tendinous fibres, which runforward between the po int o f the Olecranon and the external condyle o f

the humerus . When this structure,together with muscular fibre

,is

detached from the subjacent bones, a bro ad and thick band o f tis suewill have been preserved, c ompetent, hereafter, to extens ion o f the fo re

arm . The sub sequent steps o f the o peratio n are perfo rmed as usual .Mr . Maunder describes his o peration and gives a sketch o f the important part o f it , in the Brit . Med. J July 2 9 , 187 1 .

A new method of exc is ing the elbow-j oint in cas es of anchylosis—Mr;

Annandale having had satisfacto ry resul ts in several cases o f c ompo undfracture o r dis lo cation o f the lower end o f the humerus

,by the primary

rem o val o f the injured bone and the tip o f the Olecranon,without inter

ference with the head o f the radius o r ulna, he was led to think that incases o f anchylo sis, the remo val o f o nly a po rtion o f the lower extrem ity

EXCISION OF THE ELBOW-JOINT. 217

o f the humerus , together with any new ,o sseous material likely to inter

fere with the future m o bility o f the jo int, wo uld lead to s atisfacteryresults . In a c ase o f the kind he adopted the fo llowing plan . Hem ade two lateral inc isions , one parallel and external to the ulnarnerve

,the o ther internal to the projec tion o f the external condyle . The

ulnar nerve was drawn inwards and then the bones c leared, partly from

fil

e inner and partly from the outer inc isio n . The attachments o f the°

ceps and bic eps were left untouched. The tip o f the Olecranon wasthen rem o ved, the ligaments and the o sseous union divided, and a

c opper spatula having been passed between the anterio r a spec t o f

the j o int and the separated structures , the lower end o f the humeruswas sawn through . The head o f the radius did no t m ove freely on theulna , so the knife was carried ro und to divide adhesions , and a thinslice o f the articular surface was sawn o ff. The rem o val o f s ome smallp o rtion s o f new,

o sseous material c ompleted the o peration . Should theanchylo s is b e greater, after separating the so ft structures

, Mr.

Annandale would intro duce the narrow saw under the tricep s musc lec lo se to its in sertion ,

saw c ompletely through the anchylo sed jo int,and

then rem o ve as much o f the lower end o f the humerus as seemedneces sary . Lancet, ’ December 2 1

,

Resection of the elbowfor anchylo sis formation of a mo vable j oint.

Dr. Czerny relates, in the Archiv fur Klin . Chirurg .

’

(xiii , the

case o f a girl , set . 13 , who , in September, 1868,c ame under Dr. Bill

ro th ’s care . Three years previo us ly, she had had inflammation o f the

elbow ; the jo int had bec ome anchylpsed at an angle o f and, on

admission , there were six fistulo us o penings dis charging pus abundantly, and caries o f the ulna was detected. In the fo llowing monththe ends o f the bones were exc ised ; the portion rem o ved being threeand a half centimetres long, in the aspect o f flexion ,

and six and a halfcentimetres long, in that o f extension . The patient reco vered with ajo int which she c ould bend and extend between the angles o f 60° and

ro tation ,however, was lo st . Two and a half years after the

o peration she died o f pneum onia fo llowing an attack o f suppurationo f the knee . On exam ination ,

there was found no t much difference,in

length , between the two upper limbs ; and, when viewed externally,the jo int

,that had been o perated on ,

had a normal appearance. The

musc les near the jo int had their no rmal attachments ; the triceps wasmuch atrophied, and ended in a portion o f bone eight inches long and

three bro ad, which was un ited to the radius ; this was evidently a rn

dimentary Olecranon . There were two , distinct c o ndyles at the end o f

the humerus , having between them a.

c oncave, articular surface c o rre

sp onding with two facets on the upper end o f the radius and ulna . The

articulating surfaces were c o vered, though n o t entirely, by cartilage ;and there was a distinc t syno vial membrane .

A b oy came under Dr. Watson ’ s care w ith symptom s o f dis lo cationof the radius backwards o f some duration . There was some anchylo sis(fibrous) . E xc is ion was perfo rmed. The dislo cation was ac companiedby partial separation o f the tro chlear epiphys is and laceration o f the

o rbicular ligament. There was also partial abso rption o f the articular“ surface o f the tro chlea and new, o sseous depo sit upon the greater sig


m o id cavity o f the ulna,together with fibro us bands pas

the ulna and the humerus , c onstituting a partial , fibrousthe j o int . E d. Med. Jan . 187 1 ,An Old ca se o f dis lo cation o f the elbow

,treated by exc is ion ,

and l

a c c o rding to the antiseptic m etho d,is no ted by Dr. Marshall . Brit .

Med. May 2 7 ,Anchylo sis of the elbow ; excision of the extremity of the humerus .

The an c hylo sis fo llowed a c omm inuted fracture o f the articular extremities o f the humerus , radius , and ulna , in a patient about twenty yearso f age . Dr. Watso n perfo rmed a new an d o rigina l Op era tion . A linearinc is io n was made o ver the inner s ide o f the Olecranon ,

in the line o f

the ulnar nerve . T he latter was dis sected away with the s o ft parts andturned o ver the inner c ondyle . T he j o int was then o pened, freely, infro nt o f the interna l c ondyle, and the latter rem o ved with cutting pliers .

The external c o ndyle wa s then cut Off,thro ugh the same wound, but from

within o utwards and from below upwards , and was tw isted out o f

its bed with lion fo rceps . The end o f the hum erus was then turned o ut

and sm o o thed o ff with the saw . T he insertions of the tricep s and of thebra chia lis anticus are not interfered with, and, therefOre , the m o vementsafterwards are m o re perfec t. (

‘Edin Med. J Dec . 187 1 ,E xcision of bo th elbows —Mr. COOper Fo rs ter rec ords a c ase o f

exc is ion o f bo th elbows . Lancet ,’ Jan . 6,

E xcision of the elbowfor c omp ound dis lo ca tion—T he case o f a woman ,

set. 40, o f intemperate habits , who was adm itted into the SunderlandInfirmary , under the care o f Mr. E . A . Malins , is recorded in the‘Lancet,’ Aug. 3 1 , 1872 . The acc ident o c curred o n January 1 7th .

The dislo cation c ould no t be reduced even under chl o ro fo rm . There ;was a wound, on the inner s ide, and ano ther behind. T he latter wastenl arged and exc is io n was perfo rmed. T he patient did well afterwards .

On March 1 st the wo und was quite c lo sed. The patient co uld bendthe fo rearm to a right angle, and ro tate it without assistance . It isinteresting to no te that

,although the patient was an unhealthy syphi

l itic woman,and the parts were c on s iderably damaged, yet the result

was go o d.

” Io dide o f po tass ium was given her.

E xcision of the wris t—One o f the patients who se cas e was reco rded

in the Lancet,

’2 5th March

,1865 (case No was exhibited by Mr

,

Lister to the Med -Chir. So c . o f E dinburgh , at the end o f about sevenyears . The result was very satisfac to ry . (

‘E din . Med. J Aug.

187 1 , In o ne case,Mr. Hanc o ck made a sem ilunar inc is ion

acro ss the do rsum ,dis sec ted up a Skin flap , and pul led the extens o r

tendons aside . Lancet,

’Jan . 2 0 , Mr. Sydney Jones reco rds

a c ase ; the p atient was a male,set. 45 ; a useful hand resulted. Mr.

Lister’ s metho d was adopted. A lithographic il lustration o f the c on

dition o f the patient is given . St. Thom . Ho sp . ii,

Drawings o f a spec imen ,showing the results o f an exc is ion o f the

wrist , are given in the Brit . Med. Jan . 7, 187 1 , 1 2 .

E xcision of p roxima l p ha lanx of right thumb for enchondroma .

R

Epyes Bell narrates a case (with illustrations) in Lancet,’ Dec . 14 ,

1 72 .

E xcision of the hip j oint.—Mr. Gant mentions the fo llowing can


remaining 10 this result was no t no ted. Of the 42 , 19 c ould weout suppo rt , 9 with the help o f a stick , 1 two sticks , 1 a splint, 1 aa two crutches . In 9 the manner o f walking is no t spec ified .

o f the 5 2 rec o veries , it was espec ially n oweight o f the body. The ultimate perivaried from three m onths to five years .mo st cases, after two o r three years .the sho rtest period o f known

, permanen

c ases o f hip-jo int exc ision , extreme as to the am ount o f b

the resulting state o f the limb may still be suc cessful .two o f the autho r’ s cases , after rem o val o f four o r four and

o f th e femur with one inch m ore o f can cellated boneLancet ,’ July 15 , 187 1 , The particulars o f the

cases are given Aug. 5 , 183 .

Lectures by Mr. Hanc o ck, on this subjec t, are given inTimes and Gaz .

’

(February 24 , March 16, April 13 , 2 7 ,A review o f the who le subjec t is given ,

an

interference . He gives the number o f c ases recand the relative pro po rtion o f suc ces s under

disease.

Dr. Ashhurst , in remarking on a suc ces sful case,urges that the

o peration shoul d be lo oked on as the las t reso urce,no t to be employed

as long as a reas onable pro spec t remains o f saving life in any o ther

way. The statistics o f nearly 400 c ases to which he has references ,shows

,he thinks , the o peration to be o ne o f such gravity that it o ught

no t to b e undertaken unles s when its necess ity is very evident . T he

m o rtality was abo ut o ne half, and one in three at the m o st favo rable agefo r Operative interference . T he remo val o f the diseased bone shoul d bea s c omplete as po ss ible . Am . Jo urn . Med. S ciences , ’ O ct. 187 1

Mr. Annandale showed a spec imen ,from a case in which he had

o perated,four m onths previous ly . Fo r two months the patient didwell .

and then dropsy set in . After death,it was found that the cartilage 01

the acetabulum was destroyed, and that a kind o f membrane had formedo ver the expo sed bone. He believed that

,if the patient had lived

,this

membrane would have bec ome gradually c onverted in to fibrous tissue;and the who le o f the expo sed bone healed. He thought the case wasen c ouraging as regarded the perfo rmance o f the o peration

,m o re espe

-L

c ially as al l the disea sed sec tion s eemed to have been remo ved, and a

new jo int was apparen tly being fo rm ed. E din . Med. JSept .N o tes o f four cases under the care o f Mr. Gay are given in the

‘Lancet ’ (June 8, 15 , and 2 2 Two o f the patients were 7

EXCISION o r THE KNE E -JOINT. 221

o f age , and the o thers were 2 7 and 1 1 . Three o f them rec o vereduseful limbs . The patient, set . 2 7, died. Also see cases by Mr .

Path . Tran s , xxiii, 188.

c ase,in which the limb was sub sequently amputated, is no ted by

mu,1 1 .

. Gant9’

s experience leads him alwayssec tio n o f the bo nes the limb is ex

bones p laced in even appo s ition—no t

piece o f sponge is held on the woundT he extended limb is laid o n a padded

1k under the knee, this splint rea ching0 j ust ab o ve the heel . M r. Gant nowart o f the lateral Splin t, as thu s the heel

escapes pres sure and a subsequent tenden cy to s lo ughing . McIn tyre’

s

splint he has lo ng disused ; it no t only c auses som e pres sure on the

heel, and prec ludes ac ces s to that part fo r dres s ing, if requis ite, but thetrough , in which the limb lies , induces m o e wasting o f the mus c les thanwould o therwise ensue

,and thence , als o , lo o sening o f the splint at an

earlier period than when it m ay b e safely rem o ved fo r c leans ing, andreapp lied . Bro ad strips o f adhes ive plas ter are drawn round the limband sp lint, immediately abo ve and below the knee

,ano ther bro ad strip

higher up on the thigh , and narrow s trips aro und the ankle and in step .

A ro ller bandage is applied from the fo o t upwards , and ano ther, high up ,from the thigh downwards, leaving the knee unc o vered. An o utside,interrupted splint, well padded, and c overed with o il-s ilk abo ve and

belo w the interruption at the knee, and pro vided with a vertical fo o tpiec e, is n ow applied ; this splint , reaching from abo ve the greattro chanter downwards , and the end o f the thigh-piece well suppo rtingthe very end o f the femur externally, at the seat o f exc ision

,while the“

perp endicular fo o t-piece maintain s the leg in p o sitio n,and the upper

end o f the t ibia in steady Oppo s ition with the femoral end o f the bo ne .

E levation o f the who le lim b five o r six inches will be found to furtheraid the latter purpo se. A short, padded, femo ral splint may, als o , beplaced in fro nt o f the thigh , term inating just abo ve the fem oral end o f

the bone b ut if the external thigh-p iece be no t too wide, this anterio rsplint will scarcely b e neces sary, and he rarely uses it . The externalSplint is secured, by a ro ller bandage, from the fo o t to belo w the knee ,and

,by ano ther bandage,

from abo ve the knee up the thigh , and o verthe end o f the splint, with, perhaps , two o r three turns around the

pelvis . T he use o f the external splint is to c o unterac t the tendency todisplacement o f the lower end o f the femur

,in three directions , after

exc is ion o f the knee-jo int—projection o utwards,by abduc tion, ro tation

o utwards,and projec tio n fo rwards . Mr. Gant has had o ccas ion t o

lengthen the o uts ide splint to the axilla , s o as to c ounteract a tenden cyto an irregul ar twis t o f the trunk , to the Oppo s l te s ide, ln bed, wherebythe lower end o f the thigh 1s abducted o r everted

,with an angular pro

jec tion outwards at the knee. Rate of morta lity .

—Three general c onc lusions may be established. (1 . A dim inishing m o rtality as the

Operation has c ontinued to b e prac tised. (2 . Since the revival o f theoperation, and mo re recently, an average death rate o f one in four or


five cases . Very different death rates in the hands 0surgeons , varying from o ne, in two o r three

,to o ne in twelve

n ineteen o r even les s . T he average dura tion o f the pro ces s

is c ons iderable . In fo

the average was 2 2 5suppo sed toab o ut eightchildren ,

at St .

seven months .

o sseous unionthe weight o f

years’ free use o f the 1

been, fo r the pro ductio n o f firm ,o r perhaps o s seous union,

threeand

,to regain a useful limb

,three m onths m o re, in a starch

with gentle use o f the limb , gradually, fo r suppo rt and proResults o f twelve cases —O s seous o r firm union

,and a straigh

a ll the cases , except case 3 , where it was in complete, cases 4 and

Sp lints one m onth , when they were reappli

same interval till c onc lusion o f treatment .in one case ; secondary amp uta tion in threeU ltimate known period (1) eleven years 2 ) o n

(7) one year ; (8) o ne year and a quarter (9) one

( 10) six m o nths ( 1 2 ) five m onths . Lancet, ’3 , 187 1 , 638,Mr. Treves pas ses in review, in c onsiderable detail

,t

so urces o f failure o r o f want o f c omp lete suc cess which resulneglect o f certain precautions at the time o f the o peratithe after-treatment . W e must refer o ur readers to the

fec ting o f

s tengthen

i s riveted to the leathto within two inchesround two thirds o f

reaches from about twoischium behind, and, on as the crest o fthe ilium . These two pieces are c onnected by the piecepas ses the who le length o f the Splint

,to Within half an

extrem ity, and is firml y riveted by two rows o f rivets .

so ftened by so aking in water, and chamo is leather is pasted on itssurface . When the splint is applied, it is fixed by gum bandages .limb is laid in a M cIntyre fo r twenty-four hours , and then swung,the gum and leather are firm . Lancet

,

’

Sept. 30 and Oct . 7 , 187 1 ,463 and

Af

l

sectnre, by Mr. Ho lmes

,is published in Brit . Med. J Oct.

’

1 2, 1 72 .

The case o f a girl, set. 6, who se knee was exc ised by Mr. Can ton,is

224 REPORT ON S URGERY .

was,and had been , at wo rk as a labourer in the c o untry, an

lo ng distances . The writer says Dr . Buck was the firstwedge o f bone from the s ituation o f the j o int to remedy anthis is the operation wh ich has s ince been generally ado pteding is impracticable . Dr; Hodges g

‘ ives nineteen cases, o f

rec o vered, eight died, and amputation was perfo rmed in one

union .Lyon gives eleven o ther cases, o f which ten rec o ver

died ; eight had useful limbs , one was dis charged with firmbefo re the limb had been used ; and in o ne c ase it is merelythe patient reco vered. The autho r has c o llected n ine o ther

peration ,are given, and a tabul ated statement of eleven cases

,recent .

Am . Journ . Med. Sc ienc es ,’ April , 187 1 ,Mr. James Adam s rec o rds the fo llowing c ase

,and remarks that there

are certain c ases o f knee anchylo sis which can eas ily be cured by theOperation o f subcutaneous o steo tomy, and there are o thers in whichanything sho rt o f an excision o f a wedge- Shaped piece is who lly useles s .

Diagram s are given o f the state o f parts in his case, and the shape, &c . ,

o f the piece rem o ved by him . The patient was a lad, set. 14, fairly

nourished, but pale. The right leg was fixed at a right angle, the skin,

at the po int o f flexure, was marked by numerous c icatrices o n all s ides,

some, espec ially tho se in the pop liteal Spac e, were puckered in and ad

herent to the bones . There was abso lutely no pain o r tenderness ;there was the mo st c omplete rigidity (under chloro fo rm) the adjacentp ortion s o f the bones were expanded and ro unded

,so as to leave no in

to rval Or depress ion between them ; the po sition o f the pate lla co uldno t, with c ertainty, b e made out. The disorganization o f the jo into ccurred when he was o ne year and a half o ld

,c on sequently the limb

had been who lly useless fo r twelve years and a half ; no twithstandingthis there was no t much was ting, and no apprec iable sho rtening. Asem ic ircular flap was cut and raised. The o riginal po int o f union o f

the bones at the jo int was s ought for, but no indication o f it c oul d be

found. A cut was then made with the saw, nearly vertically, through

the femur above the c ondyles, no t extending quite through the bo ne,and this was j o ined by a sec ond, o blique cut, slo p ing from befo re downwards and backwards , meeting the first about half an inch in front o fthe p o sterio r surface. The piece between them was then remo ved, andthe remain ing po rtion broken , by flexing the limb . The ves sels were thusc ompletely avo ided. The ends were sm o o thed down with a chisel untilthe limb c ould be easily straightened. It was then put up o n a backsplint, spec ially made

,and the wo und co vered with wet lint . A certain

amount o f suppuration fo llowed, and a few abscesses required Opening.

At the end o f eight weeks there was firm union . One n o tewo rthy cir

c um stance was , that fo r several days after the Operation, the b oy was

SUBCU’

I‘ANE OUS OSTEOTOMY . 225

literall tortured by pain in‘

the back , which was attributed to his beingo bligedyto lie in a po s itio n which , fo r obvio us reasons

,he had n o t been

in the habit o f as suming. The limb , at the date o f n o te,was firm and

s traight, with less than two in ches sho rtening. A few s inuses remainedo pen . Brit . Med. O c t . 2 6

,

Dr. Watson showed to the Med -Chin So c . o f E dinburgh a wedge o f

bone, which he had rem o ved,from the site o f the knee-j o int

, in a c ase o f

Old-standing, rectangular anchylo sis . The patient was an adul t male,

and rec o vered well . He c ould walk without as sistan ce . In straightening the limb the ham string tendon s required division . (

‘E din . Med.

Journal,

’

Dec . 1871 ,Comp lete, bony anchylosis of the hneej oint subcutaneous o s teo tomy .

Mr. Little rec o rds the case o f a girl, set. 14 . Bo th knees were c on

trac ted to a right angle . The left knee was straightened under chloro fo rm

,b ut the right knee was found to b e firm ly anchylo sed . This

had resulted from strum ous disease,and the tibia was dis lo cated. A

serio us Operation ,such as severing a wedge- shaped p iece o f bone

,

seemed o ut o f the question , c ons idering the feeble state o f the girl’

s

health,but as a subcutaneous Operation ,

tho ugh po ssibly n o t suc cessful ,wo uld pro bably b e attended with little risk, I determ ined to attemptthe divis ion o f the bone, s omewhat after the method o f Pro f. G ro s s (see‘Bien . 1867-8

,2 56) o f Philadelphia .

” “ An inc is ion , a third o f

an inch long, was m ade down to the bone, through the healthy skin on

the outside o f the knee,o ver the lower bo rder o f the o uter c ondyle o f

the femur, about m idway between the anterior and po sterio r aspects o fthe limb .

”Owing to the alterations in the po s itions o f the b ones it

was impo s sible to ascertain the relation s o f parts ac curately . A strongcarpenter

’

s chisel , rather les s than a quarter o f an inch wide,was in

serted into the wo und,and driven with a mallet t hrough the un ited

bones towards the inner side o f the knee , until its po int was felt . The

chisel was then nearly withdrawn ,and then driven through again ,

s o

that its po int em erged s omewhat higher, i. e. nearer the anterio r sur

face o f the limb than befo re . This pro cedure was repeated in differentdirections . Finally

,the limb became m o vable, but c ould no t b e straight

ened, owing to c ontrac tion o f the ham strings . These were divided,but

it was c ons idered better no t to persevere in attempts at straightening.

During the next few days the girl c omplained a go o d deal o f pain . On

the s ixth day the limb was placed o n an exten s ion splint . In threeweeks she c ould put her fo o t to the gro und and walked with crutches .

'

A fo rtn ight later she walked quickly and painless ly, th o ugh with lamenes s

,without her crutches . This ca se is the first in stan ce o f sub cuta

neo ns o steo tomy, fo r the relief o f a c ompletely an chylo sed, large jo int,performed in this c ountry . Med -Chin liv,E xcision of the anh leg

’

oint.

—Mr. Gant treats o f exc is ion o f the anklej o int Lancet

,

’

Aug. 5 , 187 1 , Lateral in c is ion s are suffic ient.

M orta lity— Of 32 cases

, 7 died. Of these, 4 died o f c onsumption , and

1 o f sec ondary syphilis . The average m o rtality,therefo re

,is 1 in 16 .

Syme ’s amputation sh ows a m o rtality o f 1 in 2 8. S tate of thefo o t— Ofthe 3 2 c ases

,2 1 rec o vered with go od useful limbs . S econdary amputa

tion—Of the 3 2 , only 2 underwent seco ndary amputation, and b o th re15


c o vered. In 2 cases under the care o f the autho r, bo th patients revered with useful limbs .

Dr. W atso n showed a patient to the Medic o -Chirurgical So c ietyE dinburgh , wh o se ankle-j o int he had exc ised. The parts rem o ved,c o nsisting o f the astragalus and the ends o f the tibia and fibula

,

were als o exhibited. The patien t did well afterwards . At the end o f

ten m o nths he c o uld hear his who le weight o n the affec ted limb,and

walked smartly and readily . E din . Med. Journz,"Jan . 187 1 ,A suc ces sful case is no ted and figured in the Med. Times andMarch 2

,1872 , under the care o f Mr. Maunder.

A c ase , under the care o f Mr. Canton,is no ted in the ‘Lancet

,

’

E xcis ion of the ankle-j o int an d remova l of ta rsa l bones—Mr. Swain hashad a case under care—a b o y set. 14

—in which,at different times

,he

exc ised the ankle-jo int and the bones o f the tarsus fo r c aries . T he re

sult was go o d. Illustrations o f the s tate o f the ankle are given . Brit.Med . Jan . 7, 187 1 ,E xcis ion of the as traga lus , ma lleo li, &c—Dr. Watson employs a

single, external , J-shaped in c is ion . E din . Med. J Dec . 187 1 ,

5E xcision of the as traga lus

—Mr. G ant s tates that , o f c omplete ex

c ision , 4 cases , o nly, are rec orded in E ngland . Of p artia l exc is io n,in

2 7 cases , rec o rded, 8 were fo r c aries ; 5 term inated well, 1 ended in

chylo sis , and, in 2,the result is no t stated. Of comp lete exc is io n, 1 09

c ases are rec o rded ; 14 were fo r diseas e, 13 fo r can es,1 fo r necro s is .

Of the 13 cases , 1 died, 8 rec o vered with go od and useful limbs , 2 un

derwent sec o ndary amputatio n , two years after the excision ,and bo th

rec o vered ; in 2 , the results were doubtful . T he case o f exc is ion fo r

necro sis did well . Lancet,’ Aug . 5 , 187 1 , 18

Mr. Hanc o ck remo ved the astragalus , suc cessfully, from the right fo o to f a man set . 47 . The b one was dis lo cated fo rwards and o utwards andtwisted. There was no wo und. An inc ision was made directly o verthe bone. Lancet

,

’Jan . 2 0

,1872 ,

A case in which the o peration was done, fo r dis ease, and ano ther,fo r

dis lo cation, are given in the ‘Path . xxiii,19 2 , by Mr. T . Carr

Jackson .

E xcis ion of the as traga lus and as calcis —Dr. Mo rton remo ved the o s

calc is and the as tragalus from a lad set. 13 , o n ac c ount o f disease. Avery perfec t reco very fo llowed, bo th as regards m o tion in the new jo intand the usefulnes s o f the fo o t, which was shortened ab out one inch .

”

Am . Journ . Med. Sc iences , ’ April, 187 1 ,Remova l of bo th as traga li in a ca se of

“

severe, do uble ta lip es .—In the

c ase o f a boy, set. 7, suffering from severe double talipes , fo r whic hmuch treatment had been employed without result, Mr . Lund determ ined to rem o ve bo th astragali . A lo ngitudinal inc is ion was made

o ver the m o st projec ting part o f the head o f the bone, parallel to the

antero -

po s terio r axis o f the fo o t,between the line o f the outermo s t

tendon o f the exten so r longus and the tendon o f the pero neus tertius .

After s ome difficulty, owing to the thick ligaments , the head o f the bonewas expo sed and a gouge was applied to raise the bone, the scapho id,


the tars o -meta tarsa l articula tions —T hewho had had a p lank fall on his fo o tThere was a

lation,and sawed o ff the ends

the four remain ing metatars al bones . The disease seemed to b e c o n

fined to the po rtions o f bone rem o ved ; o n February i 4th he was sen tto Wimbledon . On Apri l 8th the wo und was entirely healed, excepta small, superfic ial s o re at the inner part. He c oul d just put his fo o tto the ground . The to es were m o vable to a very s light degree, apparently from the traction o f the extens or tendo ns being transmittedthrough the c icatrix. The sec ond to e wa s out o f the line o f the o thers ,riding upwards between the first and third to es

,which to uched each

o ther. This , however, had been the case befo re the o peratio n . The

m an was well satisfied with the c ondition o f his fo o t . ” Many stillregard exc is ion o f the ankle with disfavour ; yet, as far as I c an judgefrom a lim ited, pers onal experience, there can be n o ques tion that, inc ases o f traumatic o rigin ,

s ound union m ay be c onfidently expected, andthe patient in such c ases rec o ver rap idly, and with a fo o t little inferio rto the healthy one . Three such cases have o c curred to me and rec o veryhas been very rapid in all o f them . But exc is ions o f the bones o r

j o ints o f the fo o t itselfare still less generally practised, although the ex

p erience o f m any surgeons testifies to the great suc ces s which sometimes ensues upon the c omplete remo val o f the o s ca lc is , the as tragalus ,o r o ther single bones o f the tarsus , while, if I m istake no t

,commo n

experience also testifies to the very frequent disappo in tment whichfo llows upon gouging o r o ther partial measures . It is wo rth re

membering also that the pro spec ts o f a surgical o peration are alwaysmuch better in such c ases as can be c learly traced to a traumaticcause . Clin . So c . v

,

E xcision of the wwer j aw.—In narrating a case in which he remo ved

part o f the lower jaw in c onnection with epithelial cancer o f the fauces ,&c .

,Dr .Wats on espec ially lays stres s o n the advantages o f the plan be

adopted . He made an inc ision from the angle o f the m outh o bliquelydownwards to the base o f the jaw as far as the angle, and then upwards ,along its ascending ramus , as far as the level o f the lo be o f the ear.

The lower jaw was then divided in the bicuspid region, and the insertion o f the internal pterygo id having been divided by a sweep o f the

kn ife along the inner s ide o f the bone,the base and angle, upon the

affec ted s ide , was turned o utwards at right angles to the cheek . Thec o rono id pro ces s being affected it was neces s ary to disarticulate afterdis secting the tissues away from the bone upon its o uter o r m as seterica spec t ; this was eas ily ac c omplished by twisting the articul ar pro cesso ut o f its b ed, dividing upon the bone the parts anterio r and internalto the articulation ,

s o as to avo id injuring the internal maxillary artery .

In attacking growths at the po sterior and lateral aspec t o f the buc ca l

EXCISIONS OF THE MAXILLzE . 229

cavity,the divis ion o f the lower jaw affo rds easy ac ces s

,and entire

c ontro l o ver the bleeding . In m o st cases it is no t neces sary to extir

pate any o f the bone . If extirpation is required two th ings deserveno tice in effec ting it : 1 st

,that an inc is ion which as cends no h igher

than the level o f the lo be o f the ear suffices and thus avo ids division o f

the portio dura ; 2 nd,that in the rem o val o f the jaw ,

at the articulation,

divis ion o f the internal maxillary artery m ay eas ily be avo ided. E d.

Med. Jan . 187 1 ,In o rder to avo id divis ion o f the fac ial nerve and paro tid duct in

remo ving the inferio r maxilla, Mr. Lizars has adopted the fo llowingplan o f o perating. He made one s traight cut from the angle o f the

mouth towards the upper part o f the lo b e o f the ear as far as the p o s

terio r margin of the as cending ramus o f the maxilla ; he denuded thejaw o f its perio steum ,

the mas seter and that part o f the tempo ral musc leattached to the external and lower part o f the c o rono id pro ces s (usingthe handle o f the s calpel princ ipally) , extracted the lateral inc iso r, anddivided the jaw with the bone-

pliers (the subjec t being young) ; thenseizing the jaw at its cut end

,drew it outwards and upwards , thus

fac ilitating the rem o va l o f the m uc ous membrane and mus c les from itsinner surface , dividing the inferio r dental nerve and internal lateralligament with the kn ife , and by keep ing c lo se to the bone , avo ided theinternal m axillary artery . The c o rono id pro cess and neck o f the jaw ,

n ow being free, were divided with the p liers , and nearly the half o f the

jaw eas ily remo ved. (Communicated to the ‘Lanc et,

’

Sept . 2 8,1872 ,

by Sir W . Fergus s on .)Zumour of the lower j aw—Mr.Hamilton rec o rds a case o f c y stic tum our

o f the lower jaw , on which b e o perated suc ces sfully . The c ondyle wasdisarticulated at the jo int , and nearly o ne half o f the bo ne was rem o ved.

Dub . Jo urn . Med. April,1872 , p . A c ase under the care

o f Mr . Christopher Heath , in which he rem o ved a large fibro-cystic

tum our o f the lower jaw,is no ted in the ‘Lancet

,

’ March 2 3, 1872 ,

397, and‘Path . xxiii

,181 .

E xcis ion of ha lf of the lower j aw—Mr. W . Thomas,o f Birm ingham ,

remo ved the left half o f the lower jaw on ac co unt o f a myelo id tum our.

The growth had been rec ogn ised fo r about seven years . The left lowerinc iso r to o th was extracted, an inc is ion made along the ramus from the

c ondyle to the m edian line o f the lip , the structures dissected up , and

the j aw divided at the symphys is : after a little dis section the tum our

was remo ved by sawing the bone below the c o ndyle,and then after

wards the c ondyle was dissec ted out . The divided muc ous m embraneo f the m o uth was s titched together , and the flap o f skin laid down and

united by numerous s ilver wire sutures . The mas s rem o ved weighedtwenty -three oun c es and a half. On sec tion it was fo und to c on s ist o f athin

,bony envelo pe surrounding a mas s o f p inkish-white substance a

little firmer than brain . In its substance were two cysts . Seventeenm onths after the o peration the patient was in exc ellent healthand presented no sign o f the recurren c e o f the disease . Lancet,July 15 ,Tmnowr of the antrum excis ion of p art of the sup erio r maxilla .

—SirW . Fergusson rem o ved the greater part o f the superior m axilla for a


tum our o f the antrum . The patient rec o vered. The growth pro vedto be fibrous

,and was undergo ing c a lc areo us change . A c omplete

a c c ount o f the histo logy 1s given by Dr. G o o dhart . Med. Times and

May 2 5 ,E xcis ion of the sup erior maxilla

—A case in which Dr. G o tt exc isedthe superio r maxilla fo r encephalo id disease is reco rded in the Am .

Journ . Med. Sci,July

,187 1 , 2 89

Remova l of both sup erior maxillce—Mr. Cantoii remo ved the leftsuperio r maxilla from a wo man , set . 35 , in 1864 , fOr myelo id tum o ur,

and,in 187 1 , the o therm axilla fo r fibro us tumo ur. The defOrmity was

remarkably s light. Lancet,

’Jan . 2 0 , 1872 ,

Anchylo s is of the lower yaw ; formation of an ar tificia l j o int on each

s ide.

—Dr. Maas relates,in th e

‘Archiv fiir Klin . xiii, 42 9,

the c ase o f a m an,set . 2 7, who was adm itted into the ho spital , at

Breslau,o n ac c ount o f inab ility to Open the jaw . At the age o f 7 he

had scarlet fever ; during which , however, he was no t c onfined to the

ho use . About this time , in c on sequenc e o f a c o ld,he was seized with

severe pain in the articulation o f the jaw , o n bo th s ides , s o that he c ouldno t o pen his m o uth . T he pa in ceased

,b ut the inab ility to m o ve the

jaw increased, and became c omplete when he was 10 years o ld. Hisfo od c o ns isted partly o f fluids

, partly o f finely divided meat,which he

m anaged to thrust into his m o nth between the mo lar teeth,which were

defic ient . The shedding o f the m ilk-teeth was attended with muchdifficulty and pain the permanent teeth were arranged irregularly , andm o st o f them were displaced laterally . On admis s ion the patient hada pale , y ellowish a spect, was in m o derately go od c o ndition,

and spoke distinctly though with a somewhat muffled to ne . The upper part o f the fac e

was well developed ; but the lower jaw was retreating, and the alveo laredge was o bserved to b e far behind the c o rresponding part o f the upperjaw . Attempts to m ove the

,jaw pro duced pain in the articulatio n o n the

right s ide , but failed, utterly, in o pen ing the m outh , even when the m an

was narc o tised. Dr. Middeldo rpf made an inc is io n along the lo weredge o f the jaw on the right s ide , and, by mean s o f the chain saw and

Liston ’

s fo rcep s , remo ved a wedge-shaped p iece o f bone,having its base

below . The result o f this was that the m o nth c o uld be o pened, pas

s ively, to the extent o f about an in ch . The teeth were fo und to b e

m o stly cario us,o r to be s o abno rmally p laced as to be useles s one

mo lar on the left s ide,and two on the right, s to od o ut horizontally from

the alveo lar bo rder. The teeth were remo ved, and attempts were made

fo r s ome time to produce separatio n o f the jaws . These,however

,had

very little effect ; and,between four and five mo nths after the first

o peration ,the left s ide o f the jaw was o perated on by Dr. Fis cher in a

sim ilar m anner. Fo ur m onths after this the patient c ould vo luntarilyOpen his m outh

,to the extent o f 3 2 c entimetres and his genera l c on

dition and appearance were much impro ved.

Dr. Bo ttini , in 1 87 2 , c ommunicated a s omewhat similar case to theRoyal Academy o f Medic ine at Turin . T he patient wa s a lad wt. 1 7,who had fallen on his chin when seven years o ld. Inability to o pen the

m outh gradually set in, s o that m a few m onths he was quite unable to

separate the jaws . Bo ttin i o pened the m outh fo rc ibly during narc o s is,


was described by M . Dieulafoy,at a meeting o f theAcademy o fMe

in Paris,on Apri l 19 , 1870 . De l

’

aspiration pneumatiquecutanée

,méth o de de diagno stic et de traitement ,par leDr . Geo rgesClaim s o f prio rity were m ade by MM. Langier

Guerin,the latter stating that be had had an instrument m

same prin c iple th irty years ago .

The asp irato r may be described, shortly, as c ons isting o f

with an air-tight p iston ,c apable o f creating a vacuum ,

and a

fine, ho llow needles (o r a tro car and c anula ) fitting on to the

The latter is pro vided with an outlet as well as an inl et, eachsto p-c o ck . The syringe is exhaus ted by drawing up the

tap s are turned to prevent entrance o f air . A needletro car and canula , attached to the syringe, and thrustinto the cavity to be emptied. T he sto p - c o ck is turnedrushes into the vacuum in the syringe , witho ut the po s sibilityentering the cavity tapped. If preferred, the syringe need no t be ex

han sted till the needle is thru st in ,and thus the traction fo rce c an be

regulated. When the syringe is full the inlet tap is shut , the o ther Opened,and the p iston fo rced down . The fluid is c onveyed by a tube into a c o n

venient receptacle . Messrs . Khrone and Sesemann supp ly a fo rm o f

apparatus m o re c o nvenient in some respec ts . It c on s ists o f a large , glassjar, in the to p o f which is inserted a syringe and a tube . The syringe is ,

u sed to exhaust the glass jar. T o the tube is attached a c onvenient lengtho f india -rubber tubing, to the end o f whic h the needle o r tro car and

c anula can b e attached. This apparatus is easier to wo rk if there is alarge quantity o f fluid to be rem o ved. Cons iderable fo rce is required todraw up the piston o f the o rdinary syringe , and is tiring after a time .

Dr. Anton Lo hm ayer, o f E s seg, a fo rmer as s istant o f Bil lro th, gives ,in the W iener Med. August 5 and 1 2 , 187 1 , no tes o f 14c ases in which he used the aspirato r ; c o ld abs ces ses , hydro ps genu . ,

tum o r albus genu ., &c . This paper c ontain s an interesting, histo rical

summary o f attempts made in the same direction as that o f Dieulafoy .

Mr. Jessop gives illustrations o f the surgical uses o f the pneumatica spirato r in abdom inal tum ours

, a pelvic tumo ur, hernia, hydro cephalus , absces ses, effusio n into knee -jo int

,&c . Brit . Med.

Dec . 7,See , further, Asp ira tion of intestin e.

Clefl p a late—Mr. T . Sm ith narrates fo rty cases in which he haso perated fo r c lefts o f the hard and so ft palates under chlo ro fo rm . In

twenty-five cases , he c lo sed the who le c left at o ne o peration . In nineo f these , a c omplete cure was effected ; in eight, there was only a smallcentral h o le left ; in two , failure resul ted ; in three, only the hard palate ,

united ; in one, the so ft only, and, in two , a large ho le remained in the

palate . If it is c on sidered inadvisable to attempt to un ite the who leat o nce, Mr. Sm ith rec ommends that the part o f the c left should bebrought together, first , which seem s m o st eas ily appro ximated,whetber,

it is the hard o r s oft palate . This pro ceeding, if suc cessful, secures fo rthe m o st difficult part o f the palate a larger supply o f blo od in the

subsequent Operation . He figures a new fo rm o f gag , an impro vedneedle fo r wire , needles fo r s ilk, and a catcher ”

fo r pulling the silk

CLE F‘T PALA'I‘E—TUMOURS o r THE BREAST. 233

He only divided the musc les in a few c ases , trusting to

St . Barth . Ho sp . vn,

Mr. Franc is Mas on

plan he has ado pted fo r impro ving the vo ice after a c left o f

T he o peration m ay be perfo rmed at an y

the c lo sure . A narrow spatula is pas sed beh ind the s o ft

late and then an inc is ion is made in the s o ft palate o n either s ide,

gi

st at the inner s ide o f the hamular pro cess . T he pa late retrac ts bmuscular action and is c onverted into a lo o se , m o vable curtain

,wh ich

effec tually s huts o ff the c ommunication between the p o sterior nares

and the m o nth . A diagram is given . E leven c ases have beeno perated o n . St. Thom . Ho sp . ii , Mr . B ulkeo perated on a little girl , set . 2 1

3 ,who had a c left o f the s o ft palate ,

under the influence o f chlo ro fo rm,us ing Sm ith ’s gag . T he sutures

were to rn out at the end o f a week in a fit o f c oughing. He o perated

again at the end o f thirteen m onths,using s i lkwo rm -

gut sutures .

Perfec t union throughout the who le o f the c left resulted. Lan cet, ’O ct. 14, 1871 , 5 Dr. W hitehead reco rds two cases in whic h b e

o perated suc cessfully,the patients being anaesthetised. In several c ases

he believes bone has been pro duced in the new palate . Amer. Jo ur.

Med. Sc iences , ’ Jan . 1872 , 7 A case o f c left o f the hard and s o ft

palates o perated on suc c es sfully at one Operation, in a man o f thirtyfive

,is rec o rded by Dr. Whitehead. A spec ial gag and vario us in stru

ments , which are figured, were employed. The patient was relieved.

Amer. Journ . Med. Sc ien ces , ’ July, 187 1 ,S c is sors for remo ving sutwres .

—Mr. Thomas Sm ith uses a pair o f

sc iss o rs with a fine b o o k at the end o f one blade, and there are flat

surfaces o n each blade, behind the cutting edge , to seize the suture fastwhen divided. Lanc et , ’ May 13 , 187 1 ,Imp roved gag fo r us e in op era tions on the mouth

, (Sta—In a c linicallec ture o n ep ithelioma o f the tongue Mr. Wo od des cribes and figures agag s omewhat s im ilar to Mr . Sm ith’s

,acting on bo th sides , but witho ut

a tongue-

piece , very s trong and having a transverse c onnec ting piecepas s ing under the chin . Lan cet, ’ Sept . 2 8

,

Remova l of tumours of the breas t.—The results of Mr. Syme’s practic ein the remo val o f tumo urs o f the breast Show

,that o f fifty-five o pera

tion s which he erfo rmed, fo r s imp le tum o urs , rec o very fo llowed in a ll .

In 147 cases o fpc arc inoma, death fo llowed in 10 . T wo o f the patients

died o f sh o ck the o thers o f erisipelas o r o f inflammato ry affections o f

the tho rac ic vis cera . E din . Med. Journ .

’ July, 187 1 ,Cancer of the breast.—In the Lancet ,’ fo r Sept . 16

,1 84 1, 398, 1s

a rec o rd o f cases o f cancer o f the breast, with spec ial referen ce to thereturn o f the disease after Operation (c ompiled by Dr.Andrea Rabagliati)from the Bradfo rd Infirmary . The fo llowing summ ary is given . Out o f

1 0 patients,on whom 1 1 o peration s were made fo r cancer o f the breast

—2 died o f the o peration ; 3 have died s in ce, 1 o f return o f the diseaselo cally, and 2 died from c on stitutional return (o f these 1 in the liver'

and 1 in the lung) in 2 m o re the disease has recurred lo cally ; and in

3 there has been n o recurren ce o f the disease up to the time o f theno te . In the c ases o f the last 3 patients the longest interval betweenthe date o f the operation and the time o f the no te was nine months

,


in ano ther,the interval was five m o nths

,and, in the last, the interval was

three m onths . The disease had recurred in every one o f the c a ses in

which the axillary glands were invo lved at the time o f the Operation .

E xcision of the mam ma .-Dr. Jo seph Bell advo cates the employment

o f three in c isions instead o f the two o va l o nes usually employed. Theyare either curved, the c onvexities towards eac h o ther and leaving a

triangular space enc lo s ing the n ipple, o r V -shapedswith a cro s s piece at

the to p (base) in c luding the nipple, o r, instead o f the two latera l partso f the V , the inc is ion s may b e curved, with their c oncavities towardseach o ther and the apex below the n ipp le, o r, if m o re ro om is required,they may be c ontinued downwards after c ro s sing, curving away fromeach o ther. Figures are given . He also lays s tres s on rem o ving all

the fat and glands from the axilla if the latter is affected, and, als o , thewho le m as s o f subc utaneous fat lying in the line between the breast

and the axilla , and which c o n tains the lymphatic s extending from the

breast to the axilla . E din . Med. Feb . 187 1 ,Cystic tumo urs of the breas t.

—Dr . Jam es F. Go odhart has investigated the nature

and develo pment o f cystic tum ours o f the breast, and his results are pub lished in theEd . Med . May, 1872 , p . 10 15 , w ith illustratio ns .

Myxoma of the breas t.—Spec imens by Mr. Fo rster and Mr. Henry Morris , Path .

vo l . xxiii , pp . 2 6 1 and 2 74 .

Subcutaneous divis ion of the neck of the thigh~ bone.

-Mr . W . Adam spo ints o ut the c ases whic h he thinks adapted fo r perfo rm ing subc utaneo us sectio n o f the neck o f the thigh-bone . Six c ases have no w

been rec o rded ; five o f them , for bony anchylo s is , were suc ces sful ; one ,fo r fibrous anchylo s is in a ch ild

,was unsuc ces sful . Mr. Adam s enume

rates the spec imens o f bo ny anchylo s is which are preserved in the

vario us museum s . In anchylo s is after rheumatism , pyaem ia , traumaticinflammatio n , and strum o us disease, arrested in an early s tage , theo peratio n answers well . It is only in cases o f severe, s trumous disease ,W1th destruction o f bo ne, that the o peration i s dec idedly negatived.

Brit. Med. May 2 0,

S tatis tic s of op era tions—Mr. Sto kes pub lishes the statistics of 13 7 surgical o pera

t ions perfo rm ed by h im self from Jan . 1870 to Dec. 187 1 . (‘Dub . Journ . Med .

1872 ,P a ra centesis tho rac is .

—Dr. E vans c ontributes a paper o n thoracentes is, g ivingstatistic s and tab les of results, &c . St. Thom as

’s Ho sp . ii,

Tumour caused by the growth of a canine to o th within the antrum .—A

negro , set. 14, came under the care o f Mr. R . W . McCoy for a swelling o fthe left side o f the face . As far as a his to ry c ould be o btained it wasprobable that the tumour had been growing fo r about two and a halfyears . The tumour was punctured under the lip with a tro car and

c anula,and half a drachm o f a thin

, glairy fluid drawn o ff. The Open ingc lo sed and the tumo ur c o ntinued to increase in size. The who le o f the

front wall o f the tum o ur was then rem o ved by o peration . It was verythin and lined

,on its c oncave surface, with a thick, gelatino us substance—mucous m embrane m o rbidly thickened and degenerated. The cavity

o f the antrum was found nearly filled with this substance . In thec entre was a Space about the size o f an almo nd

,c ontain ing a little vis c id

muc us , and(pro

jec

ting into it, from abo ve

,wa s a to o th . The to o th was

firmly imbe ded in a so cket,apparently growing from the nasal pro ces s


Remova l of p haryngea l p o lyp i by the ga lvanic caut

and Go zzini (‘LO Sperimenta le

,

’

describe a

tum o ur which they rem o ved by m ean s o f the galvtum our was round, very hard, sm o o th ,pedic le to the pharynx, the upper part o fs ound, introduced through the n o stri l,wasthe uvula ; one end o f a s ilk thread was ,into the no se, and the two ends o f a plat 'and one twentieth o f an inch thick, weresilk thread was drawn thro ugh the no se

,and, by manipulating the

w ire lo op in the m o nth,it was placed as high as p o ss ible on the pedicle

o f the tumour. The ends o f the wire were then p laced in c onnectionwith the battery the c ircuit was kept c lo sed fo r twenty?s ec o nds , trac tion at the sam e time being made on the wine . T he currentwas now interrupted, and the lo o p , wh1ch had cut into the tumour, wasplaced m o re ac curately o n the pedic le . The c ircuit was again com

pleted, and the tum our was cut through at its base and rem o ved throughthe m o nth by means o f the fingers . It measured nearly two incheslongitudinally and an inch and a half transversely. The patient felt nos ensatio n o f heat during the operation ; it was no t fo llowed by pain ,

haem o rrhage, o r any dis charge .

Na sa l p o lyp us .-Dr. Lichtenberg rec o rds a case o f fibro us po lypus,

high up ln the no se, which he remo ved, from the o uts ide, by making a

flap and sawing thro ugh the nasal pro c ess o f the superior, maxil larybone

,&c . A detailed description and a figure of the o peration are

given . Lancet,’ N o v. 30 ,

Na m-

p haryngea l p o lypus ; extrac tion through the anterior nares ; bra in symp toms ;dea th .

—Mr. Fo rster, Clin. So c . iv, 159 .

Remova l of broncho cele—Dr. Greene has rem o ved large broncho celes ,succ es sfully, in three instances . The first patient was a woman, set . 45 .

The broncho cele was very large (a sketch from a pho tograph is given) .A fatal result was antic ipated

,quickly , if no thing were done , and the

patient was anxious fo r an o peration . A long inc is ion was made

through the skin , and the fas c ia divided on a directo r. Several veinswere wo unded in dividing the fasc ia immediately inves ting the tumo ur.

Their walls were so thin no ligature would ho ld. He o nly used hisfingers in c leaning the surface o f the tumour and separating it fromsurrounding s truc tures , but the hsemo rrhage was fearful . He s o on

reached the pedic le, which contained three, large arteries who se pul sations were very distinct and which served as guides fo r dividing the

pedic le into three parts , which was accomplishedwith the fingers . E achpart was tied separately ; adhes ions to the sheath o f the caro tid ves selswere found at o ne place , and their divis ion was fo llowed by c o ion s ,venous haem o rrhage . This came from the internal jugul ar, whic was

tied. T he patient reco vered well . The seco nd patient was fo rty yearso f age . The tumour was c onnec ted with the oesophagu s . There wasno t so much haemo rrhage as in the fo rmer c as e. Tw o ves sels were foundat the base ; a blunt needle was passed between these and the pedic letied'in two halves . She rec o vered well . T he third patient was thirtyfive years of age . The growth was very large, and the surface o f itpulsated everywhere . The haemo rrhage was very alarm ing. T he base

2 38 RE PORT ON SURGERY .

attempts had beenavail . The patientderived from the fac

the

lymphatic ganglia , a s suggested by M . A . Richardde Chirurgie, ’ iii) . Ano ther reas on fo r calling attention to tthe fac t that E nglish , surgical literature is m o s t remarkablythe who le subjec t o f tum ours o f the neck . In this respec tSystem o f Surgery is quite defic ient . ” Am . Jo ur. Med.

April , 187 2 , (T he n o tice in Ho lmes ’ s System m aysuffic iently large print o r detail, but is hardly quite deficieRegional Surgery, ” v .)Sanguineous tumour of the neck —A c ase in whichtum our o f the s ide o f the nec k was tapped, then laidsyringed o ut

,daily, with Condy

’

s fluid, is no ted in the Lanc et, ’30 ,

187 1 , 467. The patient was under the care o f Mr . Savo ry.

the n inth day a sudden gush o f blo o d o c curred. It wasj

sto pped imm e

diately and the c ommon caro tid artery ligatured, but the patient died.

The external caro tid artery had given way .

Remo va l of a tumour of the p a la te.

-A youngman ,set. 2 8, came under

the care o fDr. King, o f Hull, fo r a large tum o ur o f the left s ide o f the

palate , which filled up nearly the who le o f the arch o f the fauces,

the tons il being tightly s tretched o ver it . He had o nly been aware o f

it fo r three m onths,but when he disc o vered it

,he said, it was o f c o nsi

derable s ize . The man’

s symptom s were urgent, and s o he c onsented tothe remo val being attemp ted. A ligature was firs t o f al l passed round

the left caro tid s o as to b e ready fo r being tightened if neces sary . An

inc is io n was then m ade from the angle o f the m outh to the inferio rmaxilla

,a little abo ve the last mo lar to o th, and the ends o f the fac ial

artery tied. T he last two m o lars o f the upper jaw were extrac tedand the inc ision was carried back acro s s the masseter to the po sterio redge o f the inferio r m axilla . Some difficulty was then experiencedowing to the tumo ur falling back on the glo ttis . It was held up, how

ever, and the ramus o f the lower jaw divided about an inch abo ve theangle and the lower o rtion fo rc ibly drawn down . Ro om was thus ohtained to deal with t e tumo ur. An inc is ion was made to the right o fthe uvula , and the so ft palate detached from the hard palate : two ihc isions were made through the muc ous membrane, one behind, the o ther

in front, enc lo sing the tons il between them ,

and the fingers thrustfo rc ibly behind the tumour. The latter c o uld now b e drawn o ut be

tween the divided po rtions o f the lower jaw. On making a final inc ision to rem o ve the tumo ur a terrific gush o f blo od o c curred. The

ligature on the caro tid was tied and the haemo rrhage ceased. An

artery on the right side o f the palate required a ligature . T he tum o ur

was fo und to be o f a fibro us charac ter. Dr. King thought that thehaemo rrhage pro ceeded, simply, from ves sels supplying a rapidly growingtum o ur

,and that no a rtery o f any s ize had been divided. He c on

s idered the prelim inary ligature o f the c aro tid unneces sary and sho uldno t again prac tis e it . T he chief danger was from suffo cation . T he

man did well after the Operation ,as far as its immediate dangers were


latter being laid bare but no t denuded o f perio steum . The

discharged, cured, in eight days . The tum our was abouthalf in ches in its longest diameter, and weighed betweenhalf and fo ur o unces . It was enveloped in a distin c t , investand m icrOSCOpic exam inatio n showed thatvery perfect cartilage W ith a go o d deal o fFigures of the man

’s c o ndition befo re and

tum o ur,are given. Lancet, ’ July 2 9 , 1

fo r August 5 , 186, Mr. Bickersteth remarkandDr.Watson

,

* and

tum ours, properly so

ing cap sule, which islayer o f c ondensed, 0

appears to he o ftenthan make an

nall y,and then

o f the finger o r

m uch les s risk, than by the m o st elo bservation is spec ially appropriate with regard to tum o urs

p o sition we are n ow c o ns idering.

”The deep and almo st inac cess ible

p o sition o f such growths s ecures them from the ac c idental agenc iesliable to exc ite inflamm ation and c onsequent adhesions in tum ours s ituated mo re superfic ially. If it is c learly a scertained that they admit o fas much mo vement as the c onfined space in which they are lod ed per

m its,I believe they may generally be eas ily and safely rem o vedby the

m etho d I have des cribed, and without any external exc ision o r anye labo rate dis section .

”

In O ct . 1864 a woman,set . 35 , was adm itted

suffering from great difl‘iculty in swal lowing and from o ccas iono f dys noea

,caused by a growth o f firm ,

fibrous c on s istence on

side 0 the pharynx. The tum our bulged o ver to the left Sidn ot project externally as the fo rmer one did. T he tonsil waso ver it, but c ould be m o ved on it and was not adherent to it .direction , except below ,

its limwards into the lower part o f

the finger . T he tumo ur had

latterly increased rap idly, andby starvation and in imm inent danger o f suffo cation . In c is ion s weremade similar to tho se des cribed abo ve , the flaps separated and turnedup , and the tum our seized with vulsellum forceps . By the aid of the

finger the who le growth was very quickly enuc leated. It pro ved to beo f the size o f a m oderately S ized, ripe fig and o f purely fibro us strueture . The patient left , in ten days , cured.

Remova l of an exostosis from thefirs t rib—T he patient , a femal e, set .

2 0, was under the care o f Mr . Birkett . She had n o tic ed a swe lling o n

the s ide o f her neck fo r fo ur m onths . There was a hard swell ing felt,deeply p laced, o n the left s ide o f the neck, clo se to the main artery,and with the c o rds o f nerves go ing to the brachial plexus pas s ing o verit, s o that they c ould b e felt ro lling o ver the tum our. T he externaljugular vein c o ursed alo ng the anterio r margin,

and the inc isio n wasSee ‘Retro spect,

’1869

-

70, 308.

ENCHONDROMA O F THE R1Bs . 241

the vein . As little use was madehe kn ife a s po ss ible when o nce the superfic ial inc is ions had laid barenervo us c o rds . T he caro tid artery was fo und to lie in a gro o ve on

anterior surface of the tum o ur,and had to be cautio us ly m o ved

e . The tumo ur c o uld be felt to spring from the surface o f the firs tc lo se to the margin o f the s calenus . It was remo ved in two p ieces .

Birkett remarked that the ro ugh surface wo uld so on be sm o o thedhad never known a growth o f this so rt to recur . The

a thin layer o fMay 2 7 , 187 1 ,

E nchondroma of the ribs Op era tion ; death—Dr. Menzel relatesW ien . Med. NO . 15 , 187 1) the case of a man

, set. 36,who was adm itted into the ho sp ital in Vienna , under Dr. Billro th

,in

Octo ber, 1870 , on acc o unt of a tum our under the right c lavicle,which

he had first notic ed in ;the preceding January . It was five inches byfo ur in diameter, and reached from the lower bo rder o f the c lavic le tothe third rib

,and from the sternum beyo nd the line o f the n ipple . Its

surfa ce was smo o th, and it was firm and hard. The skin was no t

affected. The tum o ur was immo vable on the rib s,and was c o vered by

the pectoral musc le . It did no t pulsate, nor c o uld any bruit be heardin it . There was n o disp lacement o f the heart nor any Sign o f dis orderof the circulato ry o r resp irato ry o rgans . W ith regard to the questionof operatio n ,

it was c ons idered, on the o ne band,that if the tum o ur

were left it m ight endanger the patient’

s life by o utward growth and

co nsequent ulceration and s lo ughing, or even by inward growth and c ompres s io n o f the lungs and large ves sels ; while, o n the o ther hand

,its

remo val m ight be attended with danger from open ing the cavity o f thepleura . It was ac c o rdingly determ ined to cut down the tum o ur to thelevel of the chest -wall , and this was a c c o rdingly do ne o n O ctober 2 7 .

a c id. On the third day the

re 104o

and stated thatie wo und. On exam inatio n itthe enchondroma had Slo ughedan india -rubber catheter c o uld

enlarged, partly sp ontaneo us ly and partly by the rem o val o f necro sed

portions o f the sec ond and third ribs . On N o v. 9 dulnes s o n peronss ion was no ticed at the lower part o f the right s ide o f the chest

,and

rapidly increased upwards . On a cc ount o f the increas ing difficul tyof breathing, paracentes is , by means o f Dieulafoy’s aspirator, was performed between the eighth and n inth rib s

,and 1400 cub ic c entimetres

of yellowish-green serum were rem o ved. The patient was relieved forthree days

,but the effus ion then recurred

,and was again rem o ved to

the am ount o f 1350 cubic c entimetres ; it was now fo und to c ontainpus . After the sec ond operatio n there was relief fo r a time

,b ut the

patient was attacked with bronchial catarrh and cough , during the

16


paro xysm s o f which the lung became to rn by thegiving rise to slight haemorrhage into the tho rax. DN o vember 30 . On p o st-m o rtem exam inatio n thereexten sive adhesio ns Of the who le upperpart o f the right lunglent exudation below. T he mediastinum c o nta ined so me enc

to us masses having a gelatinous appearan ce.

Remova l of twmours from bone .—Sir James Paget is c onv

o ne growing in c o nnective tissue, and that the in stanceswhich it is right to disturb the c o ntinuity o f a bone in o rder to rem o vefrom it any inno cent tum our. He selec ts the fo ll owing cases — 1 . He

remo ved a cartilagino us tum o ur from the head o f the tibia of a lad,

set . 16 . He reflected a semilunar fla and gouged. 2 . He rem o ved a

S imilar tum o ur from the lo wer jaw Ofa lady , set. 45 . 3 . He rem o veda cartilagino us tumo ur from the radius o f a woman

,set . 40 . 4. He

remo ved a fibro us tum o ur from the walls o f the antrum . 5 . Mr .

Wrench remo ved a myelo id, pulsating tum o ur from the end o f the

radius o f a woman ,set. 43 . 6 . He enuc leated a bony tumo ur from

the angle o f the lower jaw o f a patient,set. 153. The tumour sho uld

be freely expo sed, and then turned o ut with the finger o r the go uge .

Fo r help to the diagno s is of fitting cases he suggests—1 . The tumouris probab ly cancero us if its growth c ommenced befo re puberty or after

m iddle age, unless it be a cartilagin ous o r bony tum o ur, on a finger o r

to e o r near an articulation . 2 . If a tumo ur has existed o n o r in a bonefor two o r mo re years , and is still o f do ubtful nature, it is probably no tc ancero us o r recurrent, and this pro bability increases with the increas ingduratio n o f the tumour . 3 . If the tumo ur on o r in a bone has do ubledo r m o re than doubled its s ize in six m onths

,and is no t inflamed, it is

pro bably cancerous o r recurrent , and this pro bability is increased if,among the usual c o inc idences o f rapid growth , the veins o ver the tumo urhave much enla rged, o r the tumo ur have pro truded far thro ugh ulceratedo penings , and bleeds and pro fusely dis charges ichor. 4 . If with anysuch tumo ur, no t being inflam ed, the lymph-

glands near it are enlarged,it is probably can cerous , and still m o re probab ly if the patient have lo stweight and strength to amo unts mo re than propo rtionate to the damageo f health by pain o r fever o r o ther acc ident o f the tumo ur. 5 . Atum o ur on the shaft o f any bo ne but a phalanx is rarely inno cent, andso are any but cartilaginous o utgrowths o n the pelvis , o r any but the

hard bony tumours on the bo nes o f the skull . If on the éoncurrenceo f these characters o r o n o ther grounds it is in any case conc luded thata tumour c onnected with a bone is no t cancerous or recurrent, thequestio n whether it is growing on or in the bo ne may be made pro bableby attending to the fo llowing po ints —When the wall o f the bone can

b e traced o ver the surface o r any part o f the surface of the tum o ur, itsgrowth from w ithin is nearly certain , and so it is when ,

o n the surface of

the tum o ur, po rtions o f bone can b e felt am ong po rtio ns o f mo re yieldingsubstance . General smo o thness o f surface is usual ly s ignificant of a

tum o ur growing within a bo ne and expanding it , unl ess in the ease o f

cartilagino us tumo urs , which , after growing within bones, have pro


had been s aid to slip up and down) , abo ut the size o f a 3 2 -lb . S

enc lo sed in a firm cap sule . It was fibro - cartilagino us in s tructFrom its upper part a firm band had pa s sed upwards . This waswith in the operatio n as a pedic le o f the thickness o f the thumb ,tied befo re being cut . T he man rec o vered. He was a tailo r, andno tic ed the tumo ur about seventeen years . A figuretumo ur is given . Lan cet

,

’

Aug . 5 , 187 1 ,M edullary carcinoma in the axilla .

-Mr . Durham rem

lo id tumo ur of the armp it fro m a man set . 48. The tgrowing abo ut five m onths , and was sec onm o le abo ve the elbow . Med . Times anOs teo id canteen—An interesting but s omewhat Obscure

o steo id c ancer o f the ulna,&c .

,is detailed by Dr . Jo seph Bell .

Med. May, 187 1 ,Multip le lymp homa trea ted by arsenic .

—Billro th des cribesWiener Medezin . N o . 44 , 1871 , the case o f a

who was affected with un iversal hyperp lasia o f the lymphaticOn each side o f the neck was a tum o ur as large as a fist, and

fauces lay o ne (pro ceeding from the tons ils) as largAs this pro duc ed dyspnoea, it was remo ved by theThere were als o tumo urs , as large as app les ,and a s large as hens ’ eggs in the bend o f the elbo wterio glands were felt to be enlarged, and the spleenn o rm al s ize . There was n o leukaem ia . Rec o very to oweeks under the use o f Fowler’s s o lutio n . In suchremarks

,subcutaneous injec tio n and electro lys is have

to have any effec t in reduc ing the s ize o f the tum our .

R ectilinear e'

cra seur.

—Dr. No tt des cribes and

écraseur. It m ay be c o mpared to a pair o f se'

sho rt , stro ng and’

serrated—to crush—and the ban

provided with a s c rew, by means o f which theexerted. In treating extern al haemo rrho ids thethen cut o ff. In internal piles the écraseur is app licand then a ligature is tied in the gro o ve fo rmed by thesafety . The crusher may be used in any case in whichis deemed advisable . The tis sues are squeezed together and then a

cut is made in fro nt o f the écra seur, o r after this is taken o ff,thro ugh the line o f indent-ation . In amputation o f the penis no

bleeding o c curred, and the tissues quickly united. He remo ved a

finger by crushing thro ugh bo ne and all . The end so o n heal ed o ver.

Am er. Journ . Med . Sc i April,1872 ,

Trea tment of tumours by subcutaneous inj ection—In a paper on thissubject, read befo re the Surgical Congress in Berlin ,

in 1872 , and

published in the‘Archiv fur Klinis che Chirurgie,

’ xv,Dr. Heine

remarks that the high expectations which were fo rmed when Thiersc lland Nns sbaum called attentio n to injections into the parenchyma

,as a

m eans o f destroying tum ours have no t been realised. We believethat, hitherto , surgeo ns have not had c lear idea s a s to the o bject to beattained, and that they have a cted rather emp irica lly in regard to the

cho ice o f the fluids to be injec ted and to their strength . Again, the

TREATMENT O F TUMOURS BY SUBCUTANE OUS INJE CTION . 2455

ca ses , in which the treatment ha s been tried, have been tho se in whicho peratio n appeared unadvisab le, and in wh ich , therefo re, no c onvinc ingresult c o uld he expected. In primary cancer

,the treatment o ught to

be tried at the earliest stage o f the disease . In his paper, Heinereferred to cases in which , after the injectio n of a watery so lution o f

carbo lic a c id,cancer of the paro tid and indurated syphilitic ulcers and

papulse were sa id to have been reduced. In his experiments on c ancer

he m o dified the operation by injecting the fluid chiefly into the

periphery, so a s to act on the yo ungest pro liferating cell s,to bring

their growth to a standstill,and to prevent the es cape o f the cancero us

elements into the neighbo uring lymphatic glands . A woman, set . 48,

the m o ther of three children ,had had a tum our of the right breast fo r

a year,and one o f the left fo r six m o nths . Their external appearance

and an exam ination o f exc ised po rtion s showed them to b e carc inomatous . From the left breast an indurated c ord o f lymphatic s led to an

enlarged axillary gland o f the s ize o f a chestnut,and in the neigh

b ourho od o f the same breast several small,hard no dules were embedded

in the skin . A so lution o f chlo ride of z inc (0 °

5 to 1 per cent . ) wasinjected in the neighbourho od o f the breast several tim es (the quantityused being from five to seven charges o f Pravaz

’

s syringe) , butproduced o nly severe pain ,

without any effect on the s ize o f the

tum our . On O ctober 3 1 Dr. Heine began to inject a s o lution o f 1

per cent . o f hydro chlo ric ac id in quantities represented by from two to

five charges o f Pravaz’

s syringe, at intervals o f twelve or fourteen

days,the injectio ns being made between the breast and the

At the end of eight m onths a no table reduction in the s ize o f the

tumours was o bserved. T he enlargement of the axillary glands andthe indurated

,lymphatic c ord disappeared in a m onth from the c om

mencement o f the injection . One gland, only, was rem o ved fo r thepurpo se o f micro scOpic exam inatio n,

and showed that the cancer- c ellmasses were broken down into a hom ogeneo us , finel granu lar material .The ain produced by the injection wa s slight . A ter the third injection ever set in and lasted three m onths in Heine ’s opin ion it c ou ldbe only regarded as an abs o rption -fever. It was treated with quin ine,and with carbo lic ac id in eight-grain do ses in pills ,with the effect

,on ly,

o f tempo rarily reduc ing the temperature about 33° Fahr . The numbero f white c orpusc les in the blo o d was in creased. At the end of the

treatm ent,the reduction had am o unted to 4s”; c entimetres , transvers ely,

and vertica lly,in the left breast ; in the right, to 5 c entimetres

transversely, and only 13 vert ically . On one o c ca s ion,when the injec

t ion was om itted fo r a tim e,the right breast increased in size . At

the end o f the eighth m onth the woman was in go od health , the feverhaving for some time left her . In two o ther cases , o ne of ulceratedmammary cancer in a woman and o ne o f s econdary ulcerated cancer o f

the inguinal region in a m ale,injectio n o f hydro chloric ac id pro duc ed

febrile symptom s, m o lecular melting down o f the tumo ur, and partia lshrinking . In two instances , Dr . Heine endeavo ured to reduce hypertrophy o i the pro state by injec ting so lution o f iodine

,made by m ixing

60 parts of tincture o f and 8 parts o f io dide o f po tas s ium in

As Dr.Heine practises at Inn spruck, h e probab ly refers to the Austrian tincture,


180 parts of water. The fluid was thrown in p er rectum by m eans ofPravaz

’

s syringe . The first patient died a fortnight after the treatment was c ommenced, o f o ld- standing cys titis and pericystitis

,with

pulmonary oedem a . The injec tion did n o t appear to have had anyeffect on the pro state . In the sec ond ca se the s o lution used fo r injection c on s isted o f 60 parts o f iodine and 4 o f io dide o f po ta s s ium in 10 2

o f water. It pro duced pro static ab s ces s , which spread into the rectum ;and the patient had ep ididym itis fo r some days . The lo be o f the

pro state, which wa s enlarged to the size o f a walnut,wa s entirely

reduced in s ize . In the discus s ion which fo llowed the reading o f Dr.

Heine ’s paper (see Berliner Med. July 8,1872 ) Dr .

Billro th sa id that he had tried paren chym atous injection s in the trea tment o f tum ours

,but the result had been negative, and be for som e

m onths desisted from their us e . Having heard, however, of the

injec tion o f bron cho cele and lymphoma with tinc ture o f iodine by Liicke,o f Bern, and o f the o b servations m ade by R . Dem ene, o f Bern, hedeterm ined to give the plan ano ther trial . His late ass is tant, Dr .

Czerny, made a number of experiments on the injection ,in cases of

strumous enlargements, tum o urs o f the lymphatic glands , and cancer,o f so lutions o f. nitrate of silver

,chlo ride of go ld, perchlo ride of iron

,

c arbo lic ac id, ga stric juice, &c . The result,s ometimes

,was the forma

tion o f a small absces s,which left a little scar, but had no influence o n

the growth o f the tum o urs . In some instances,the resul t was a rapid

increase o f the tum o ur,and

,in o thers

,n o result at all wa s Obta ined.

Billro th also related a case in which a single injection of alc o ho l in a

case o f s trum ous disease of the lymphatic glands was fo ll owed bysloughing and death .

Sup ra-s terna l taxa tion of the c lavic le—Pro f. R .W. Smith rec o rds the

fo llowing case, ac c ompanied by two illustrations . A man,int . 60

,fell

down from and was run o ver b a vehic le he was driving. He was found

to have sustained a c ompo und uxation o f the astragalus of the right fo o to utwards . The bone was easily repla ced. T he sternal end o f the leftc lavicle was dis lo cated. The sho ulder had fallen in

,towards the mesia l

line, s o far that the end o f the c lavic le was pres s ing s trongly on the

trachea , caus ing a very great amount o f dyspnoea . It fo rm ed a verystriking projection in front o f the trachea, giving to the sternal po rtiono f the masto id muscle an arched line ; it wa s a c omplete luxation . In

a sitting po s ition the dyspnoea and dysphagia were extreme . Whenthe man was plac ed in a recumbent p o s ition the bone no longer ro

jected, but it sti ll remained abo ve its proper level . The m an diedp onthe eleventh day. W hen the integuments were rem o ved from the

sternal region ,the end o f the left c lavic le wa s seen lying abo ve the

s ternum,beyo nd the c entre o f which it had so far pa s sed a s to be in

c ontact with the inner edge o f the right sterno -ma sto id musc le . The

s terna l po rtion o f its own mus c le cro s sed in front o f it at some distanceexternal to its articular surface, wa s arched forwards and in a state o f

tens ion , while the c lavicular po rtion was relaxed. Po sterio rly, the bonerested o n the sterno -hyo id musc les and the front o f the trac hea . The

wh ich , acc ording to Squire, c ontains o ne part o f io dine in seventeen o f rec tifiedsp irit.


u wards,acro ss th

0 the axilla . In

trunk being fixed,

ro tating the arm in s o do ing, and, ladepressing it . Prac tically this p lanvessels . Clin . So c . iv

,196 . See also previous

E wtrava sation of blo od after the reduc tion of a dis lo cation

shoulder .—Mr . C . De Mo rgan rec o rds the case o f a m an

,set . 5

c ame under care a fortnight after the reduction o f a dis lo cationsho ulder under chlo ro fo rm and with the heel in the

Med. Jan . 6 , Mr. Rivingto n rec ords the case o f

a man,set . 7 1 , who died in c onsequence o f haemo rrha e from a

traumatic , axillary aneurism ,resulting from the reduc tion ofa dislo ca~

tion Of the humerus . Brit. Med. Apri l 2 0 , In the

Brit . Med. J May 18,1872 , is rec orded the case o f a man

,wt .

38, who dislo cated his humerus and had it reduced. He was thenadm itted in to the Northampto n Infirmary . G angrene Of the arm

ensued and the man died. Fracture o f the c o rac o id proce s s , chipping

pf the head o f the humerus

,and rupture o f the axillary artery

,were

ound.

Dis lo cation of the wris t—A case has been under the care o f Mr.

E richsen . The ac c ident had oc c urred long before . The carpus wasdisplaced on to the palmar aspec t of the bones o f the fo rearm and to

the ulnar s ide, and the trapezium c o uld be distinctly felt in front o f andto the ulnar s ide of the end o f the radius . After m anipulatio n the

p o sition o f the parts was much impro ved . Med. Times and

O ct. 14, 1871 ,Congenita l dis lo cation of the wris t—Spec imen from an Old woman

bro ught to the dissecting-ro om . (Mr. James Adams,Path .

xxii,

Comp lete, simp le, anterior luxa tion of the s emilun ar bo nc .—Dr. Chiso lm

narrates the fo llowing case. A sailor,set. 2 5 , fell from the yard-arm o n

to the deck, a distance o f about twenty-five feet . He fell onside with his right hand doubled under him . Ten days later he came

under Dr. Chiso lm ’s care . There was c omparatively little swelling.

The axis Of the hand was perfec tly in a line with that o f bo th radiusand ulna . A large, hard, rounded, subcutaneous prom inence existed on

the front o f the wrist,directly o ver the site Of the sem ilunar bo ne .

This was so firmly fixed as to exhibit no t the s l ightest m o tion whenman ipulated with fo rce . The p o int o f a c ouching needle thrust, to thedepth o f an inch, into the back o f the wrist showed, by the freedom o f its

DISLOCATION OF THE BONE S OF THE PELVIS . 249

vacant c avity existedwhere,normally

,

nd. T he c onstant pres sure kept upcaused fo rced and painful fiexion o f the fingers and

All attempts at reduction were u seless . Three weeks after theDr . Chis o lm rem o ved the bo ne thro ugh a s ingle inc ision ,

tw o

in length , in the median line . The Operation was m o re tediousas expected. T he bone was ro tated s o that the c oncavity fo r theon o f the ro unded head o f the o s magnum lo oked directly up thehilst the c onvex surface belonging to the radio -carpal jo int was

fac ing the fingers . All the ligaments were n ot to rn through , but theb one was fo rced am o ngst them ,

twisted and stretched o ver it s o that itwas tied down firm ly in its new po s ition . Its reduction would havebeen quite impo ssib le, owing to the irregular surfaces o f bone in c ontac t .A small fragment o f the scapho id was found attached to the sem ilunar

,

torn Off at the time o f the injury . Lancet,

’O ct. 2 8

,187 1 , 60

Dis lo ca tion of the bones of the p elvis.

—Dr . Sallero n c o ntributes an

elaborate m em o ir o n the subject to the Archives Généra les de Medec ine, fo r July andAugust, 1872 . During a period o f fo rty years

,there

have c om e under his no tice, in the m ilitary ho sp itals , m o re than thirtycases o f severe injury o f the pelvis, m o st of them being instances o ffracture with dislo cation ,

Often c omp licated with o ther severe injuries ,and rap idly fatal . In three cases , there was s imple dis lo cation witho utfracture . In one o f these, a man

,set . 2 6

,fell from a height of twelve

metres,and dislo cated the left iliac bone, upwards and backwards ; the

sec ond p iece o f the sternum was also dis lo cated upwards and fo rwards,on the first . Reduction was readily effected by fixing the pelvis ,applying steady extension ,

by a towel‘

placed round the thigh , and pushing the po sterior, superio r, iliac spine downwards and forwards .

Attempts were made to reduce the dis lo cation of the sternum,but

witho ut effect . The patient left the ho spital, able to walk withoutcrutches , about seven weeks after the receipt o f the injury . In ano thercase

,a Zouave, set . 36, dis lo cated the right iliac bone fo rwards and

slightly upwards , by a fall from a height o f five o r six metres . On

pla c ing him on his back,the right antero -superio r Sp ine o f the ilium

was seen to be ten o r twelve m illimetres higher than the left , and the

right pubic bone projected fo rward, beyond that o f the o ther side . The

crista ilii was nearer to the false ribs on the right s ide than o n the left .There was n o impairm ent o f the m o vements o f the hip

-jo int . On

turn ing o ver the patient, in o rder to make a further exam ination,Dr.

Salleron felt a sudden m o vem ent,a cc ompanied by a s o und which wa s

heard by the bystanders . T he patient at o nce felt relieved, and them anipulation o f the pelvis became les s painful than it had been . On

again p lac ing him on his back,the projection forwards o f the right

antero - superior i liac Sp ine had nearly disappeared, and the right pub icprom inence quite s o . The patient was dis charged, c onvalescent, nearlyseven weeks after the acc ident . In a third case

,a man

,set . 2 8

,was

injured by a mass o f lim e-stones fall ing on him,from a height o f four

o r five metres . T he left iliac bone was dis lo cated forwards . The Signsof the injury were distinct , although les s marked than in the case justrelated, and the patient was unable to lie on his back witho ut pain. As


the patient was in a state o f nervo us exc itement, and the displaceme

was not very stro ngly marked, Dr . Sallero n deferred any attemptreduc tion . On the fifth day, while the patient was turn ing him self

b ed, he felt a sudden sho ck in the

which his neighbour (no do ubt with ex

being as lo ud a s a p isto l-sho t, but whi

by a man in the third bed from the patient .he was able to lie c omfo rtably on his back .

ho sp ital, three m onths after the receip t o f

to lerably well, but the right thigh was s omewhat atrophied. Its c ondition had impro ved, somewhat , when he was s een twenty dayswards . In a subsequent po rtion o f his memo ir Dr. Salleron treats

,

at length , of the patho logy , symptoms , diagno sis , progno sis , and treatm ent o f dislo catio ns o f the pelvis . P a tho logy

—In disjunction o f the

pubic symphys is, the interarticular cartilage is not (except, perhaps, inexc eedingly rare cases) torn through its central part , but is separatedfrom the bone on one o r the o ther side . This has been no ti ced byMalgaigne, Backer, and Clo quet, as well as by Dr. Sallero n . The

fibro us ligam ents surrounding the symp hys is are m ore o r les s torn .

The inferior ligament is generally detached from the interarticularfibro -cartilage, and torn away from its attachm ent to the descendingramus o f the pubic bone that is deta ched. Its lower edge seem sto be usually uninjured, but its upper bo rder is irregularly to rnto a greater or less extent, espemally at the sides

,where it is

attached to the bone. Laceratio ns o f the perinaeum and rupture o f

the urethra or of the bladder, altho ugh produced simultaneously withthe dislo cation

,are no t pro duced by it . Rupture of the bladder

general ly arises from direct pressure . The wo und in this case is linear,

and has well-defined edges, while in erforation of the bladder byfragm ents (which , in rare cases, takes p in cases o f disloc ation com

plicated with fracture) the edges o f the wo und are irregular . Re tentio n o f urine or dysuria may o ccur in c onsequence o f the deviatio n of

the pro static portion of the urethra to one o r the o ther s ide . T he

prec ise mechanism of this displacement requires to be expla ined bypo st-m ortem exam ination ; but Dr. Salleron believes that it arise s fromthe manner in which the puho -pro static ligam ent

,on the side of the

dislo cation,is affected. When it is merely stretched

,the pro state and

the urethra with it are drawn towards the affec ted side ; when it is to rnthrough , the pro state and urethra are displaced towards the Oppo siteside . This displacem ent of the pro state has been no ticed in o ne case

by Richerand, and in two by Dr. Salleron . In displacem ent o f one of

the pubic bones directly fo rwards,there is no injury o f the triangular

ligament and no deviation o f the urethra from its c ourse . Simpleluxation of the sacro -iliac articulation m ay be artial o r c omp lete . In

the partial form ,the ligaments uniting the ilium to the sacrum are

to rn , whil e the ilio -lum bar ligam ent is only partial ly lacerated. The

ilium becom es som ewhat tilted,SO that its upper portio n is carried

s omewhat forwards , and its lower part c o rrespondingly backwards . The

tubero sity, which lies behind and a little below the po sterio r, su rior,

iliac Sp ine, passes beyond the p o sterior edge of the articular surfidiie of

25 2 RE PORT ON SURGERY .

further back than that of the o ther s ide. The crest o f thenearer the false rib

felt (if there be no to r leSS backwards,o ther S ide the ho llow o f the sacrum is increased.

the S ide o f the injury is raised abo ve the o ther, and iles s o utwards and fo rwards , acc ording to the extent o fro tation o f the ilium . The disp lacement o utwards isappro ximation o f the

T avigno t has rec o rded

b ut it is o nly appa

superior, iliac spinec onsequence o f the ro tation o f the ilium

,the fo o t i

s ometimes to such an extent as to imitate frac turefemur (as in cases described by Enaux and Gerdy) .iliac bone fo rwards

,the transverse diameter o f the

and the di

iliac Spine

at all,injured

, but, s ometimes , the sens ibility Of

In bo th form s o f dis lo cation there is deep- seatedilio -S c iatic regions , increased by the slightest,espec ia lly by pressure with the fingers . Activeis abo lished, o r is restricted to Slight flexion o f

wards , there is no c ompress ion o r lac eration o f the nerve-trunks to such

the luxation is unac companied by fracture, the bladder and urethra are

generally uninjured. Oc cas ionally,however

,rupture o f the bladder has

o c curred in such cas es , pro bably as the result o f direct pressure duringthe ac c ident . E xcept when the c o c cyx is dis lo cated fo rwards

,there is

no disturbance o f the rectum . In the three c ases o f s imple dis lo cation,Observed by Dr. Salleron

,the displaced iliac bone was c ompletely

imm o vable. Ke has des cribed an instance where the ilium was dis

lo cated backwardsand the finger co uld be laid in the sacro - iliac jo int.In this, however, the bone must have been displaced outwards . When

REDUCTION OE OLD DISLOCATION OF THE EEMUR. 25 3

bo th il iac bones are dislo cated backwards , and espec ially when there isalso luxation of the pubic symphysis , the severity Of the injury and o f

eneral ly, renders the diagno sis easy . In ca ses where thethe visceral lesions are n o t s o

and large vessels being torn ,

pelvis and sometimes into thesion s there are alm o st alwaysOther c omplication s

, o f whichpo ss ibility, are c ontus ion of the

ac c ount o f

c a Trea t

ment. —Dr . Salleron advises immediate attempts at in al l casesOf dislo cation o f the pelvic bo nes , whether fractui e b e also present orno t. The patient mu st be kept lying

'

on the back in a state of abso luterest

,and any c omplications that arise must be treated acc ording to

their nature.

Reduc tion of a dis lo cation of the femur after fi ve and a ha lf months .

Dr. M ‘Kee rec o rds a case . The patient was a woman who was thrown out

o f a tra on the left knee . She was at a distance from any advice . Afterfive an a half m onths the dis lo cation was diagno sed and reduced bymanipulation under chlo ro form . There seemed to b e some tenden cy inthe o ther hip to become dis lo cated during pregnancy . Great diflicultywas experienced in keep ing the femur in its place after reduction . l t

s lipped o ut once , but returned with an audible snap . (‘Am Journ .

Med Sc iences ,’ Jan . 187 1 ,Dr. James Norton no tes a case o f dislo cation o f the femur backwards

and upwards , with fracture o f the acetabulum,which was reduced afi er

three months . Brit . Med. Jo urn May 2 7, 187 1 .

Unreduced dis lo ca tion of the femwr .—Mr. MacCo rmac describes a

spec imen Of unreduced dislo cation o f the femur. The patient was a

man, set. 70 . A weight o f metal casting fell o n him ; his abdomen was

injured extens ively . The symptoms o f the dislo cation were invers ion o f

the limb,the thigh was flexed and rigid, the amount o f Shortening was

diflicult to m ake out. AS the patient lay in bed the knee rested abovethe patella of the so und thigh . The head o f the bone could with ditficulty be disc overed lying near the sc iatic no tch . The tro chanter was in a

plane som ewhat po sterio r to the no rmal S ituation . The head o f the femurwas found to have been displaced alm o st directly backwards ; it restedbehind the acetabular ridge opp o site the m iddle and upper part of thegreat s c iatic fo ramen . The anterior part o f the capsule remained intact .The tendon o f the obturato r internus was below the head. The Spec imen


c onfirmed mo st o f Bigelow ’ s views . An illustration is given .

Thomas ’s Ho sp . ii,

Simultaneous dis lo cation of bo thfemora .—M r.William Po llard reco rds

a case in a man, set. 5 3 . T he right was thrown into the thyro id fo ramen

and the o ther o n the dorsum . Reduction was effec ted by manipulation .

Two m onths later, he c ould walk perfectly . His rec o very was delayedby an attack o fgo ut in the left fo o t . St. Barth .Ho sp . vi ii

,10

Hip and shoulder dis lo c a tio ns a nd their reduc tio n without trac tio n, by Rusb ton

Parker. Brit. Med. J Sept. 7,

Dis lo cation of the lonee.—A man ,

set 50 ,Slip ed from a ladder and

severely lacerated the s oft parts o f the calf o f t e left leg and the Skino f the popliteal Space, and als o dislo cated the left tibia o utwards andS lightly backwards . After two months he came under the care Of Mr .

E richsen . At that time the leg was fixed nearly at a right angle and

was quite useless . With the aid of chloro fo rm the reductio n was

effected witho ut any great difliculty . Med. Times and Gazette,

’

O ct . 14, 187 1 ,S im ultaneous dis lo cation of the three cuneiform bones —An instance

o f this extremely rare injury is quo ted in the Gazette Med. de Paris,

’

Dec . 30 , 187 1 , from the Gaz . Med . de l’

Al gérie.

’ It is described byDr. Bertherand. The subject was a man, set . 3 7, an infirmier, who fello n the so les o f his feet from a height o f fo ur metres . After beingunder treatment fo r Some time, he left the ho spital c ompletely disabledby lamenes s . When M . Bertherand saw him

,the right fo o t was

s trongly flexed o n the leg, espec ially o n the inner side . T he first threemetatarsal bones , with the cuneifo rm bo nes

,were raised

,fo rming a

higher plane than that of the do rsal surface of the fo o t . On the ex

ternal Side o f this elevation was a vertical surfac e c ons isting o f the

o uter surface o f the third cuneifo rm bone detached fro m its articula tionwith the cubo id. On the inner s ide was a depress io n , increas ing c o n

siderab ly in this directio n the normal c oncavity o f the plantar arch .

Behind, there was ano ther depress io n, the upper surface o f the s ca

pho id lying lower than the back Of the cuneiform jo int . In this cavitythe tendo ns o f the tibialis anticus m usc le, on the inner s ide

,and o f the

extenso rs of. the to es , o n the o uter s ide, were felt very distinctly . T he

fo o t was atrophied the tars o -metatarsal j o ints were nearly ankylo sed,

and the length o f the inner bo rder of the fo o t was sho rtened to the

extent o f abo ut 15 millimetres . The patient walked o n the heel o f theaffected fo o t, it being impo ss ible to bring the first three to es to thegro und.

Subastraga lo id dis lo cation of the fo ot—A case of dislo cation of thefo o t inwards from beneath the astragalus came under the care o f M .

G o s selin in January, 1872 . T he fo o t was turned inwards,with the

under border lo oking upwards there was a ro unded projection on the

exterior s ide o f the fo o t,in front o f which a depressio n c o uld be felt,

and, o n the inner s ide , was a depression having an antero -

po sterio rdirectio n , at the bo ttom o f which the inner malleo lus c o uld be indistinctly felt . Reduction was readily a c co mp lished under chlo ro fo rm .

Gaz . des Hopitaux, ’ 10 Février,

25 6 REPORT ON SURGE RY .

which,though the bone was

tailed into o ne ano ther that they were held firm ly in a curved po s itio n ,

~

separated at the c o nvexity of the curve, jamm ed together at the

c oncavity . This Spec im en was n o ticed on a fo rmer o c cas ion,but

it was no t then sketched. Dub . Journ . Med. April,

A s innp le method of removing s ilver wire when emp loyed in

un im itedfra c ture .-Mr. Mas on invites attention

'

to a m o difi catio n ofthe plan o f transfixing and ho lding the fractured ends in appo s itio n withtwisted wire . He operated on an unun ited fra cture of the ulna and

radius . The sm o o th surfaces o f the ends of the ul na were sawn Ofl'

diagonally, so that when p laced together the new surfaces accuratelyc orresp onded. A ho le was bored o bliquely through them , and a needlewas pas sed thro ugh the ho le . T he needle wa s then enc irc led with a

lo op o f wire, the ends o f which , having been firm ly twisted o n themselves , were made to emerge, together with the needle

,from a sma ll inc i

s ion in the skin , placed at right angles to the larger wo und. By re

m o ving the needle the wire wo uld be at once disengaged. The radiuswas treated very sim ilarly . The wire was finer and carried ro und theneedle in a figure of eight . Mr .Ma son suggests that it is po s sible that thedivis ion o f the fibrous bond o f unio n may be dispensed with, the needleand lo op of wire being alo ne employed that the needle may be sho rter,s o as no t to press on the neighbo uring struc tures that ivo ry o r o thermaterial m ay be used in the p lace o f the needle ; and, la s tly, that thewire

,being released

, may be left to wo rk its way o ut , its remo va l, ifrequired, being effec ted at any tim e by tractio n . Med -Chir .

liv, 3A clinical lecture o n delayed union and non-union of bones by Mr.

Callender will be found in the Brit. Med. J N ov . 30 ,1872 . He

alludes to Obstructed veno us c irculation a s a c ause o f delayed union .

He mentio ns a case in which union was delayed fo r ten months—frac tureo f the thigh-bone . In the case o f a so ldier the humerus did no t unitefor two years and a ha lf . In ano ther cas e the femur did no t unite fo rtwo years . At St. Bartho lomew’

s there has been but one case in two

thousand five hundred fractures . He alludes to abscess o f the bone,

foreign bo dies between the ends , want o f appo sitio n, fractures near a'

Oint, &c .JWrist-drop from p ara lysis of the masculo -sp ira l nerve in fra c tures of

the hum erus —Prof. E richsen remarks that injury to the mus culo -sp ira lnerve in fracture o f the humerus must be o f rare o c currence, fo r he ha s

met with no instance reco rded in any standard work . He had himselfseen three instances quite recently . When the main trunk is injuredc omplete wrist-drop is produced. When the po sterio r intero s seo usdivis io n is injured, the lo ss o f supination and Of extens io n is no t so

c omplete. The sup inato r longus and extenso r carp i radialis longio r,being supplied by bran ches from the main trunk , are no t paralysed, andthus a certain

,though very lim ited ,

mo vement in the sense o f sup inationand extension is preserved, though the forearm and hand fall natura lly intostate Of pro natio n and flexion . T he first case was that o f a woman , wt.

2 9 , who fell and fractured her humerus about the middle ; ten weeks

FRACTURE o r OLECRANON —ATROPHY o r MUSCLE . 25 7

rds,She had marked wrist -drop . The symptom s are given at

There was a difference o f temperature, o n the two s ides, o f 5

°

The thumb and index-finger were numb when the fingers wereflexed, She c o uld extend the j o ints between the first andsec ond and third phalanges . This was evidently ac com

ricales (figures o fthe hand ands flexed, a slight, supine mo ve

by the patient, pro bably due to the action Of thecase was that o f a woman

,set . 30 , who fell on her

elbow, and was found to have sustained a c ompound fracture of theexternal condyle o f the humerus . She c ould no t raise the wrist o r thefingers when the hand was pronated . There was some power Of supination and als o o f extension

,probably due to the extensor carp i radialis

longio r and to the supinato r longus . T he muscles supplied by thepo sterior intero s seo us nerve were paralysed, the radial had escaped .

She c ould feel in the fingers and there was no lo ss o f temperature . The

third case was one Of fracture o f the lower ep iphysis o f the humerus,

wrist-drop from paralysis o f the po sterio r intero s seous nerve and tonicc ontraction o f the fingers . T he patient was a girl set. 7 . She hadfallen o ver a cro quet h o op and the lower part o f the right humerus wasfractured . She had very marked wrist-drop , but c ould eas ily extendher wrist

,her hand was pronated and c ould be but imperfectly sup i

nated. The fingers were flexed and drawn into the palm o f the hand.

She c ould use the intero ssei and luinbricales ; the flexo r tendons weremuch contracted ; the arm was smaller than the o ther. There was a

difference in temperature, o n the two sides , of 8°o r Lancet

,

’ July 1 ,187 1 ,Fra cture of theo lecranon in each arm ; a trophyofmusc le.

—Mr.Hutchins on no tes the case o f a man , set. 2 7 , who was adm itted into the LondonHo spital , who had fractured the Olecranon pro cess on each Side

, and (ashe stated) ruptured the tendon o f his calf. These ac c idents had all

happened several years befo re . Two years befo re adm issio n,he frac tured

the right Olecranon, by falling on his elbow from the rigging o f a sh ip,a height Of about ten feet . He had the arm put in Splints in a straightpo s ition for three weeks . Since that time he had had no power to liftthe arm straight in the air abo ve his head the fo rearm falls into extremeflexion as so on as its centre o f gravity gets to the proximal S ide o f the

elbow . The tricep s o f the right arm was fo und to be wasted and quiteflabby when he tried to straighten the arm , that musc le did no t ac t inthe least . The upper fragment o f the Olecranon was Separated

,by at

least an inch , from the lower one . Five years later, he fractured the leftOlecranon by a somewhat Sim ilar ac cident, falling ab out four feet . T he

arm was kept straight in splints fo r Six weeks, after which time he so onregained perfect use o f the limb . The upper fragment was found to be

m o vable on firm pressure, b ut he had perfect use o f the triceps and hismusc le was apparently quite strong. The fracture appeared to havebeen oblique and there was strong, fibrous un ion . He met with a thirdac cident

,about eighteen m onths befo re, in which he pro bably ruptured

the tendo Ach illis on the right side . He jumped o ff a table, and on

alighting felt as if something had struck his right calf. On examining17


it he found a little “ dent into which he c ould putrest in b ed for a time, he could walk as on adm ission .

o n careful exam ination ,a Slight Swelling at the

and m iddle thirds o f the calf,o r perhaps r

measured half an inchwas quite perceptible

only the tendon o f the gastro cnem ius before its junction withThe calf o f this leg was c onsiderably weaker than that o f ththat he c ould not stand on tip

-to e on the c o rresponding fo o twith the left fo o t. Mr. Hutchinson remarked that no

assignable fo r the o c currence o f these injuries . T he healthno fractures o f any o ther bones had o c curred. The

c ondition o f the two arm s was probably due to the toright one. He thought it was no t diflicult to Obtainthese fractures , although very diflicult to get a ctual bone .

interest to no te that abso lute atro y o f the tric eps on the right s ide byno mean s disabled the arm . In t is respect the case was parallel towhat happens after atrophy o f the quadriceps exten so r o f the thigh .

The man c ould use the arm well , except in extension ,and fo llowed a

labo rious o ccupation without discomfo rt . The reason why a musc leShould s tropy in c onsequence o f non-un ion o f the bone into which it isinserted is no t quite obvious ; but Mr. Hutchinson has repeatedl yn o ticed this result after badly united fractures o f the patella, and sometimes very go o d ones . He had never befo re no tic ed it after unun itedfrac ture o f the Olecranon . Lancet

,

’ July 2 9 , 1871 ,Fra c ture of the head of the radius .

- Spec imen described by Mr. James AdamsPath . xxu,

Fracture of the ilium by mus cular vio lence—A case o f frac ture o f the

anterio r, superio r, spino us pro cess o f the il ium from muscular vio lenceis repo rted in the Am . Journ . Med. S c iences

,

’Jan . 187 1 , 2 77 . T he

patient was under the c are o f Drs . S . Jo y and J . W . McWhinnie whorec o rded the case in the Canada Med. J Sept ,

1870 . A verym uscular youth

,set. 1 7 , in turning at a certain po int while runn ing in

a fo o t race, felt something snap in his right hip , walked a few ste S andfell . “ On exam ination distinct m o tion and crepitus could be fialt bypressure o ver the pro cess , also by plac ing the thumb o ver the o rigin Ofthe sartorius and ro tating the thigh . The fracture extended into then o tch below, but there was no great tendency to displacement Save whenthe leg was abducted, thus placing the sarto rius upon the stretch, thepro ces s doubtless being partially kept in place by the fibres o f the tenso rvaginae femoris aris ing from this pro cess on the one hand, and Poupart

’sligament on the o ther, when tens1on was taken Off the sartorius . ” The

patient was kept in bed with the thigh flexed and the Shoulders raised.

In two weeks the patient made a go od reco very without displacementremaining.

A

po t

gier case is reco rded by Mr . Hyde Brit Med. J Nov.

9 , 1 72

260 REPORT ON SURG ERY .

o f the atlas o r the transverse ligament . 2 . T he o donto id pro cesless liable to be fractured by external vio lenc e than the b o dy of

axis at the insertion o f the pro ces s . 3 . T he o do nto id pro cess is n o tfra ctured by being driven against the tran sverse ligament o r anterio rarch of the atla s . 4 . The o donto id ligaments have a c ombined strengthgreater than the o donto id pro cess . I am satisfied, however, that theeffic ient agents in this fracture are the o donto id ligaments . ” He deta ilsvarious cases under the heads Of Spontaneous fracture ; fra c tures fromdirec t vio lence from external vio lence applied to the fo rehead, the backpart of the neck , S ide of the head frac tures with S light symptom s atfirst ; multiple frac tures ; fracture fo llowed by exfo liation and reco veryfrac ture and reco very with the formation o f a false jo int . He d is

cusses the vario us m odes Of death and the symptoms the chief being,that the patient carries the head suppo rted on his two handS . Am .

Journ . Med . Sc ien ces , ’ Oct . 1871 , 3 38

Unilatera l dis lo ca tion of the fifth c ervica l vertebra—Dr. Reyburnrecords the case o f a man

,set. 2 4 , who sustained a unilatera l dislo ca

tion o f the fifth cervica l vertebra by a weight falling on his neck .

Paralys is gradua lly came on . After n ine weeks and two days reduc

tion was effected with impro vement in the symptom s . Death o c curreda fo rtnight later . There was no fracture . An abs cess was fo und inthe c ord. Remarks on o ther cases rec o rded are made . Am . Journ .

M ed. Sc iences, ’ July 187 1 ,F racture of the sp ine.

—A case of fracture o f the fifth cervica l vertebra , with la ceration o f the spinal c o rd, and c omplete para lysis belowthe ro o t of the neck, in which the patient lived fo r three m onths

,is

rec orded in the Am . Jo urn . Med. Sc iences , ’ April, 187 1 , 590 .

T he rela tive morta lity of ana logous inj uries in c ivil and m

practice—Dr. R . Vo lkmann ,

o f Halle, ho lds Archiv . fur

Chirurg ,

’xv) that the mo rtality after injuries and Operations is no t

greater in military than in c ivi l practice ; o n the contrary,tha t it is

even les s . In 1699 gunsho t fractures o f the bones o f the leg, o c curringin the wars o f the last ten years , and the statistic s o f which wereco llected by Billro th , there were 40 1 deaths , o r 2 36 per cent. and in

1 09 cases which came under Dr. Vo lkmann ’ s no tice, there were 2 5deaths o r 2 2 per cent . On the o ther hand, in 885 c omp licated fractures o f the leg, o c curring in various Germ an and Brit ish ho spitals ,there were 339 deaths o r 385 per cent . In o ne ho spital alone (St .

Bartho lom ew ’s) the m o rtality was lower than in m ilitary prac tice,being 2 0 per cent . In m o st o f the German ho sp itals the mo rtalitywas 40 per cent . W ith regard to the ca ses of gunsho t fracture of the

leg in which attempts were made to preserve the limbs,Vo lkmann

finds that, in the Italian war,the m ortality was 1 7 per c ent . Am o ng

the 109 patients under his care at Trautenau, amputation o f the thighwas p erformed in 18 ca ses , and 9 Of the patients died ; while , in 9 1

cases in wh ich he emp loyed c onservative treatm ent,the m ortality wa s

16,or 1 7

°

5 per cent . Billro th,at W o issenburg, and So c in ,

at Stettin ,

had a m o rtal ity o f abo ut 14 per cent . amo ng the cases treated c o ns c r

vativc ly ; and Stromeyer, in the Danish war, had a m o rta lity Of o nly10 per cent . On the o ther hand

,of 3 2 0 patients subjected to c o nser

MORTALITY o r INJURIE S IN CIVIL AND MILITARY PRACTICE . 261

vative treatment in c ivil ho sp itals , 1 2 0 died, o r per cent . Withregard to c omp licated fractures of the femur, Vo lkmann has hithertobeen able to c o llect only a lim itedamount of statistic s from c ivil practice .

Injuries Of this kind generally o c cur in c onnection with railway a cc idents, acc idents with ma chinery, blasting o f ro cks

, &c .,and demand

primary amputation . Dr. Frankel ha s c o llected 140 cases in c ivilpractice which were, at least at first, subjected to c onservative treatment o f these 85 died, o r 60 per cent . This rate o f mortality isabo ut the same that has been Observed in m ilitary practice after fracture o f the shaft o f the femur by gunsho t . In the mo re recent ca ses

,

the rate o f m o rtality has been even les s . Vo lkmann him self had 44deaths in 95 ca ses

,o r 46 3 per c ent . Am ong the 885 cases o f c omp li

cated fracture of the leg referred to as having o c curred in c ivil practice,there were 1 77 amputations ; the perc entage m ortality after the

primary amputatio ns was 60 , and after the secondary, 77 . On the

o ther hand,amo ng the 3813 cases in m ilitary prac tice c o llected by

Billro th the death -rate was only per c ent .Having given these statistic s , Vo lkmann go es on to say that, in c om

plicated fractures in c ivil practic e, the soft parts are m o st injured ;while in m ilitary surgery the bo nes suffer m o st, being Often very extensively fissured . The statistics

,already referred to

,Show that the

injury o f the so ft parts has a m uch greater influence on the m ortalitythan that o f the bones—an influence even greater than has generallybeen supp o sed. Again,

the result in gun sho t fractures depends muchless on the extent o f the injury of the bone than would be ap riori expected. Vo lkmann has several times bad the opp o rtunity o f examining,after death , bones (inc luding the femur) in which from twelve to twentyfragments o f various sizes had become c onso lidated

,and where no

necro sis had o c curred, no Sp linters had been removed, and the defo rm ityof the limb was no greater than after an o rdinary fracture . The m ere

extent o f the fracture and the number o f Splinters, he, therefo re, ho ldsno t to afford suffic ient ground fo r primary amputation . S imp le fra ctures are very rare after bull et wounds . He has m et with only two o r

three instances among m any hundred cases o f such injuries . Gunsho twounds o f the jo ints , a lso

,may heal witho ut suppuration o r necro s is .

Comp ound frac tures o f the leg o c curring in c ivil life as the result ofindirect vio lence

,and presenting but s light injury to the soft parts

perhap s a c lean cut-wo und—appear (at least in the larger ho sp itals) tob e attended with a higher m ortality than Sp lintered fractures from gun

sho t . In cases o f death after fracture o f the leg, in c ivil practice, thefatal event o ccurs

,in 50 per c ent .

,within the first fo rtnight . In gun

sho t fractures Of the same part, on the o ther hand, death do es not o c cur(exc ep t in rare cases) until the third week . The cause o f this markeddifference i s thus explained —In c ivil practice these patients who diewithin the first fortnight are carried Off by acute septic pro cesses . Aftergunsho t wounds , o n the o ther hand, the m o st acute and rap idly destructive

,septic

, phlegm onous pro cesses are seldom o r never m et with .

Of s loughing phagedaena after a bullet wound,Vo lkmann met with n o

examp les ; in o ne case under his c are, where gangrene o ccurred, he

fo und injury of the large vessels , with much extravasation of blo od.


Lo cal reaction sets in later and m ore s lowly after gunsho t wouha s no t the sam e tendency to advance as after o ther injuries . A num

b er o f patients, indeed, die o f septicaem ia after gunsho t wo unds ; but, inthese cases, there are alm o st always fo und purulent dep o sits around theends o f the bones , presenting a much m o re lim ited character than thediffused dep o sits met with after comp ound fra c tures in c ivil prac tice .

The c omparatively small am ount o f injury o f the s o ft parts, and the

less exten sive, lo cal reaction ,must have a favorable influence o n primary

amputation in the field. But, leaving this subjec t, the difference in them ortality after intermediate amputation in c ivil and in m ilitary prac ticeis no tewo rthy, and has been no ticed by Bill ro th as well as by Vo lkmann .

Amputation performed as late as about the sixth day after the inj ury,

fo r gunsho t wound, is in m any cases a s suc cessful a s primary amputation . But after this comes a perio d extending to the eighth week , inwhich extensive inflamm ation prevails

,and (at least as regards the

thigh) a patient o perated on in this stage very rarely survives . The

discussion which fo llowed the reading o f Dr. Vo lkmann’ s paper befo re

the Surgical Congress in Berlin i s reported, at length , in the BerlinerKlin .W o chenschr .

’fo r May 6, 1872 . Dr. von Langenbeck , the pre

sident,could not agree that infiltration o f the wounded parts does no t

o ccur to the same degree in m ilitary, as in c ivil practice . In extensive ,gunsho t fractures o f the femur, at least , swell ing and all the symptom so f sepsis Often appear within twenty-four hours SO rap idly, indeed, asscarcely to allow time fo r primary amputation properly so -called. T o

this he was dispo sed to attribute the great m ortality fo llowing theo peration . He agreed with Dr. Vo lkmann that the different am ounto f danger in c ivil andm ilitary practice was due to the relative amo unt o finjury o f the bone and o f the so ft parts . Injuries from cannon balls o rfragm ents Of shel ls m ay very c lo sely resemble certain injuries o ccurringfrom acc idents in civil life. But there is a great difference in the resultbetween an entire separation o r a mere crushing o f the soft parts .Laceration o f the soft parts by splinters o f Shells are attended withrelatively small danger, even when the bones are no t injured ; and,when the bones are injured, death o ccurs at a later perio d than in c ivilpractice . Cases where the soft parts were contused by canno n ba llswithout a large Open wound, were, in his o pin ion,

much m o re liable toseptic infiltration than tho se in which the soft parts were extensivelylaid Open . Dr. Bardeleben thought that Dr. Vo lkmann attached to olittle importance to the injury o f the bones . Dr. Busch had alreadyn o ticed the greater m ortality after severe injuries o f the leg in c ivilthan in m ilitary practice . Referring to injuries o f the knee

,he

rem arked that Severe wounds from axes,&c .

, o ften o ccurred in c ivi lpractice

,and m ight be c ompared with gun sho t wounds . As far as he

knew,m ore than half the cases o f knee-jo int injury treated conserva

tively in m ilitary surgery were suc ces sful ; but this fell far short of c ivilpractice, where he c ould remember only two deaths in a number o f

injuries of the knee that had c ome under his no tice . He agreed withDr. Langenbeck as to the frequency o f purulent oedema after gunsho twounds, and had been struck with the number o f cases o f this wh ich hesaw at Metz, even after resection o f the elbow and sho ulder jo ints . Dr.


a clot extended for some way abo ve the divided end of the vessel .two o f the cases

,the po sterior tibial and the p o pliteal were the inju

arteries . Gaz . Med . de Paris, ’ July 2 2 ,

Gunshot inj uries of bone.—Spec im en s exhibited by

Path . xxii,

Fowrfo ld, gunsho t woundin the ‘Wiener Med . We

m an,set . 40 , who fo r the

and thirdtween theribs . He

lying dresjected, atThere was m o derate haem o rrhage from the

the chest on the left s ide c ould scarcely b e perceived respirationlaboured and stertorous and the heart ’ s action was weak . On

third day, he had rec o vered suffic iently to be undressed and put to b ed.

A bullet was now felt lying under the Skin below the angle o f the leftscapula ; but as it caused no inconvenience

,it was no t rem o ved. The

o ther ba lls c ould not be fo und. The patient went on well for abo ut aweek

,when he was suddenly attacked with repeated paro xysm s o f

dyspnoea , which were relieved by cherry laurel water and acetate o f m o r

phia . Fo r a time,again ,

there was impro vement ; but, on his attemptingto leave his bed, fo r a s ho rt time

,in the third week

,he was again seized

with dyspnoea, to which were now added lo ss o f appetite and s leeples sness . This state c ontinued till the eighth week, when he had rec o veredsuffic iently to leave his bed and go into the Open air. Three m onthsafter this injury

,he went to the Tyro l where he Spent the summer

,

and returned in better health than he was in befo re the injury .

Gunsho t wound of the neck retention of the ba l l for eight months .

M . Baum cs c ommun icated the fo ll owing ca se to the Surgical S o c iety o fParis

,in O ctober, 187 1 . In the preceding January, an o ffic er was sho t

in the right submaxillary region . Haem o rrhage o ccurred several tim es,

but was always arrested by p lugging with charp ie . Fo r some days afterhe received the wound, he was treated in the ho sp ita l OfLa Pitié, underMr. Trelat . It was fo und necessary to perfo rm tracheo tomy, which wasattended with difliculty by reason o f the general swelling o f the neck .

After its performance , the breathing became free, and the swellingdim inished. The canula fell out c asil the wound s o on c lo sed

,and

the breathing remained normal . Still t e part which had been woundedremained enlarged, and fistulous o penings presented them selves in the

neighbourho od. On introduc ing a pro be, it struck against a fo reignb ody

,but o f its nature o r S ize n o idea could be fo rmed. The patient

had an Ob scure no tion that something was remo ved when he first cameunder treatment after being wounded. At the end o f eight m onths

,the

parts remained indurated. An abs cess now fo rmed,and burst into the

m outh, allowing an examination to be m ade with ease . A hard bodywas now felt lying deeply in the submaxillary region : it was remo vedthro ugh an external inc is io n

,and was found to be a musket-ball weigh

TREPHINING FOR GUNSHOT. 265

ing 2 15 grammes (more than 75 o unces) . Gaz . Med . de Paris,

’2 1

Oc t.

Tre

phining f or Gunshot.—A case is rec orded in which a so ldier was

woun ed in the fo rehead by a bullet . After ten days “a spo t was

disc overed, a little to the right o f the o c c ipital pro tuberance, that waspainful when touched, and had the appearance o f being a very s lightportion o f the o cc ipital b one forced by s ome power from within out

ward.

”The wound in front was exam ined m ore carefully . T he fro ntal

in such a manner as toagain . A probe was

head in the imthe les ion o f the o c c ipital bone, where it met

a hard, c onvex substance. The o cc ipital bone was then trephined, anda bullet extra cted. The man rec o vered. Am . Jo urn . Med. Sc iences

,

’

Jan . 187 2 ,Dr. Halstead reco rds S t. Louis Med. and Surg . Journal

,

’ March,

1870) the case o f a m an; set. 1 7, who was sho t in the head by thebreech-pin o f his gun .

) The pin struck his fo rehead, smashed in the

b one,and stuck into the brain . T he man pulled it out himself and

then rode o n horseback fo r some distance. He afterwards became insensible. Pieces o f b one were fo und driven for two inches into the

brain . As m any as thirty-eight pieces were remo ved,and also a three

fourth inch s crew. It wa s supp o sed that the breech -

pin passed nearlyto the petro us bone, a distance o f four and a half inches , it is Said, fromthe fo rehead, tearing the falx c erebri and open ing the superior, longitudinal sinus in its passage . T he injuries , &c .

,are described in detail .

The man who lly rec o vered. He was no t in any respect aware o f anydifferen ce, three m onths later, in his m ental o r physical c ondition, fromthat befo re the acc ident . Am . Journ . Med. Sc iences

,

’Jan . 187 1 ,

30 1 )Dr. Howard narrates the fo llowing case in detail . On April 6,

1862,a so ldier, set . 19 , was sho t in the head by a Minie ball . He

staggered, fell back, and remained in sensible till the next day . On

April 9 he was found sitting up , lean ing against a tree, and sens ible.

On April 15 he was carefully exam ined. There was a wo und in the

left temple, and a probe pas sed o bliquely acro s s the m o st prom inentpart o f the fo rehead and emerged through a small inc ised wound

,said

to have been made by a surgeon who extracted a ball, which the patientsaw . Just above this inc ision was a slight depression in the frontalbone . T he left leg wa s numb . After a few days “ symptom s o f c om

pres sion”

came o n . Coma bec oming alm o st c omplete, it was determ ined to explo re . On April 2 1 , a triangular depression was found in

the centre o f the fo rehead, the apex o f the depressed po rtion was

chipped o ff,leaving a small o pening no t admitting a probe . In this

was entangled a single hair. This at once suggested the presence o f a

fo reign body beyond. The trephine was applied. A Minie ball wasremo ved from a depth o f two inches . The patient recovered. Fromthe appearance o f the ball it seemed pro bable that a po rtion had

chipped Off,remained under the Skin

,and had been rem oved by a

surgeon . The remainder entered the Skull and fo rmed a trapd o or


aperture, the lid springing into place as so on as the ball passed. Whythe ball should have entered the skull, at all, at a po int beyond thegreatest c onvexity o f the forehead, is no t to b e ac c ounted fo r ; but theultimate reco very o f the patient is the m o st remarkable feature in thecase. The narrato r has failed to find ano ther case o n rec ord in whicha m issile out of reach and o ut o f sight has been disc o vered and remo vedfrom the brain by trephining— a permanent rec ove afterwardsresulting. A diagram o f the fracture is given and o f the

r

hall . (Ibid. ,

O ct . 187 1 ,Gunsho t wounds of the lower

’

extremity .

—Mr. MacCo rmac writes avery interesting paper on his experience o f the treatment Of gunsho twounds o f the lower extrem ity . He quo tes statis tic s from E nglish,French, German , and American authorities . In the Anglo -Americanambulance, Mr .MacCo rmack and o thers treated in all

, 47 cases o f gunsho t fracture o f the femur. In 2 1 o f these

,amputation was perfo rmed ;

16 term inated fatally . E xcluding disarticulation at the hip , the

mortality was 7 2 2 2 per cent . 2 6 cases were treated witho ut amputation

,many o f them being in a ho peless c ondition . One half died. If

an attempt is made to save the limb it is better to avo id any strenuousefforts to remo ve the defo rm ity . If amputation is determined on

,it

should b e done within the twenty-four hours . In the ambulance, 5 7

cases Of gunsho t fracture o f the leg were treated, with 2 3 deaths . 2 5were treated conservatively, with 8 deaths, o r 3 2 per cent . while 3 2required amputation . Of these 13 died, o r 406 per cent . Of the

operation cases , 16 c onsisted o f primary amputation,with 5 deaths, and

16 were secondary amputations , with 8 deaths . As regards injuries tothe hip-j o int, the American statistic s given in the Surgeo n

-General ’sCircular N0 . are referred to . (See last Injurieso f the knee and ankle-j o ints are dis cussed. Mr . MacCormack sumsup The considerations detailed in this paper appear to me to afford

gro unds fo r c onc luding against the universal application o f amputationin regard o f gunsho t fractures o f the Shaft o f the femur. S ound, tho ughit m ay b e delayed, union will o ften fo llow c onservative treatment . Ithink

,fo r general guidance, we may, fo r the present, dec lare that ,

fractures o f the lower half o f the femur,the rule Should be, when in

doubt, to amputate, while, in tho se Of the upper half o f the bone, theconverse should apply, namely, when in do ubt to try to preserve thel imb .

”Two plates o f illustrations o f injuries to the femur and to the

tibia acc ompany the paper. St . Thomas’s Ho sp . ii

,

D ep ressedfractur e of the sha l l in a child,with deep laceration of the

brain ; no symp toms for six days ; death from c onvulsions on the eighthday—Mr. W . Adams Path . xxiii

,

Comp ound, dep ressed fractur e of the skul l ; Op eration—Dr . Meldon

rec ords the case o f a b oy, wt . 7 , who was kicked on the head by a ho rse .

Two c ompound, depressed fractures Of the Skull were found. On adm ission, he was

“ sem i-consc ious ; one pup il was c ontracted and theo ther dilated.

”The depression was “

an inch in depth .

”T he bone

was elevated and p ieces rem o ved from each po sition . In one place thedura mater was found lacerated. Hernia cerebri resulted from thispart, and was c ontro lled by pressure. At the same time, however, there


insensible. After a whi

the quay,a distance o f

insensible,and remained

examination

sensibility c ompletduce the slightestA stellate fractureb one was rem o vedpres sed. T he dura mater was intensely CODand bulged, hern ia-like, out Of the Opening.

it,letting out only turbid serum . Impro vement fo llowed. The respira

tion ceased to b e stertorous , the pulse ro se to 64, the left pupil became

les s dilated, and sensation was restored to the c o rneas . He so o n re

lapsed, however, and died ab out thirty-Six hours after admis s ion . Atthe p o st-m o rtem ,

on remo ving the c alvaria the membranes were fo undintensely c ongested, and a large absces s between the dura mater and

the bone was fo und pres sing on the left hem isphere . It was a remarkable c ircum stance that the abscess was n o t fo und immediately c onnectedwith the portion o f depres sed bone . It is

,I think

,a c irc um s tan ce

much to be regretted that the o peration o f trephining and elevating thedepressed p o rtion o f b one was n o t perfo rm ed when the symptom s o f

pressure first manifested them selves . (‘Dub . Journ . Med . Dec .

Trep hiningfor abs cess within the cranium—Prof. N . R . Sm ith relatesBaltimo re Med. J Dec . 1870) a c ase t—A c lergyman received

a blow from a Sharp stone o ver the left parietal bone . Separation o f a

small sequestrum fo llowed. There remained a fistulous o pening, whichnever c lo sed during the long period o f twenty years . When he came

under care, exam ination with a pro be, through the fistula , showed a

cavity two and a half inches in depth between the bone and the mem

branes o f the brain . T he S inus was sma ller than a quill . Trephin ingwas pro ceeded with . The bone was fo und o f ivo ry hardnes s

,and much

thicker than c omm on,and o f unequal thicknes s . T he Op eration was

pro ceeded with, however, without hesitation , as the mem branes wereknown to b e far remo ved from the inner surface o f the bo ne . Whenthe p iece was lifted up ab out three ounces o f fetid pus es caped. NO

cerebral disturbance fo llowed. The patient “ entirely reco vered, and

rema ined well some time afterwards . Am . Journ . Med . S ciences , ’April, 187 1 ,T rep hining in cerebra l disease—A paper, by Dr. W . Pepper, on thissubject , with the narrative Of a successful case

,will b e found in the

Am . Jo urn . Med. Sc iences,

’ April,187 1 , 4 1 1 . T he patient was a man ,

set. 2 1 . He had suffered from c o nstitutional syphilis,had febrile sy mp

tom s like tertian ague, intense headache, left hem ip legia , strabismus andp to sis , increasing c oma and sterto r

,and a node o n the right frontal

bo ne . Anti- syphilitic treatment failed to give relief.Inj ury to the brain —Mr

,Callender n o tes three cases o f injury to the

brain and tabulates o thers , with the Object o f directing attention ,first,

TUBERCLE OF THE URINARY TRACT . 269

queney with wh ich c onvuls ions o r rigidity are as so c iated witho f the left s ide o f the b ody a s c omparedwith tha t o f the righ tto the o ccurrence Of these symptom s in cases o f injury o r dis

hem isphere wh ich lie abo ve theliii

,

3 ba se of the bra in —Dr . Brownnts o n guinea-

p igs , was struckare altered c on secutively to a

frequent causes o f death waspneumonia . He made spec ial experiments to ascertain the immediateeffects o f an injury to the brain o n the lungs . The results Obtainedwere startling. In almo st al l cases o f injuries by crushing o r sectio n Of

the pens Varo lii ec chymo ses were found in the lungs . ” Injuries to o therparts of the base were fo llowed, sometimes , by the same effects , and itis extremely probable that a slight pres sure upon the pens by effusedblo od is suflicient to pro duce it . Injuries to the medulla and Sp inalc ord rarely pro duced an effusion in the lungs . Many experiments haveShown that it is no t thro ugh the par vagum ,

but through the sym pathetic nerve, espec ially by its Sp inal ro o ts , which throw them selves intothe first tho rac ic ganglion ,

that the peculiar influen ce o f the irritatedpens V aro lu exerts itself

, pro duc ing a pulmonary haemorrhage.

”' T he

c ondition o f the lung, as regards disten s ion or co llap se o f the air-cells,

do es no t seem to influen ce the production Of haemo rrhage . It is no tessential that there be a c ontinuation o f breathing. Haemo rrhage isno t the only result ; an anaem ic c ondition ,

oedema,and emphysema c an

also be pro duced. The latter c an o c cur when no t a Single resp irato rymovement takes p lace after an irritation o f the base o f the brain , eitherby crushing or cutting . Lancet

,

’Jan . 7, 1 87 1 ,

Tubercular dis ease of the urinary mucous membrane—Mr. Thomas

Smith writes on this subjec t, with spec ial referen ce to the symp tom s,&c . ,

during life . He quo tes vario us autho rities to Show what has beenalready written respecting the disease, and then expla ins that his paperrefers to what is o ften called strum ous o r scro fulo us disease o f the

urinary, mucous m embrane,and which c ommences as a tuberc ulo us in

fil tration o f the submucous tissue o f some part o f the gen ito -urinary,

muc ous membrane (pro bably m o st o ften first in the kidney) . T o the

naked eye it first appears as a yellowish , cheesy depo sit, though in itsearliest stage it is stated to b e a depo sit o f grey o r m iliary tuberc le .

Later on in the disease it is Often as so c iated with tuberc le o f the sub

stance Of the testis, the bo dy o f the pen is, o r the pro state . It m o stlyaffec ts tho se wh o are o f a tubercular diathes is , and o c curs befo re the

m iddle period o f life . He describes the c ondition,o f the urethra

,

bladder, ureters , and kidneys in advanced stages but we pass on to thesymp toms Patients suffering with this malady are sure, some time

'

in the c ourse o f the disease , to fall under the susp ic ion o f being thesub

'

eets o f stone indeed, it would b e true o f alm o st al l to say that theearfy symptom s much resemble tho se o f renal c alculus , the later, tho seo f stone in the bladder . In the earliest stage o f the disease the sym ptom s may b e such as to exc ite but little attention,

and fo r which m edicaladvice is no t generally sought, being, perhaps, a slight aching in the

REPORT ON SURGERY.

back,a little blo od in the urine, a transient pain in the testic le o rgl

penis . By degrees the bleeding becomes m ore cOpio us , the pain inback m ore severe, and symptom s Of urinary irritation appear, in an

creased frequency o f m ic turition ,in pain in the glans penis, in

bladder,o r in the perinaeum . In children t

water,shrieking, shuddering, and pulling th

glans penis, the child sometimes finding a tempo rary rewater has passed. In the later Stages o f the disease thebladder and the urinary distress is mo st severe, and therein the hypogastrium . T he urine, which from the first isline

,may c ontain no thing abnormal but blo od and broken

lial scales . After a time it’ c om es to b e lo aded with puo ffensive . I have o bserved that the qualtity o f the uringreat variations, that it may, at one tim e, be ful l o f blo o d, at ano ther,free from it ; that the pus may disappear and again reappear. Ah

scesses may form in the lo ins , pro state, vesiculse, perinaeum ,body o f the

penis, o r testic le ; and these are preceded, in the last-named o rgans ,by depo sits o f tuberculous matter, which may be rec ognised as indurations o r lumps some time before the fo rm ation o f m atter. U rinaryabscess o r extravasation i s no t rarely the result o f these suppurations .In a c ase (a b oy) under Mr. W o rmald

’

s care,in addition to very severe

urinary symptom s, pho sphatic depo sits c ould b e detected with a soundin the muc ous membrane o f the bladder. The blo o d in the urine maybe bright c o loured

,as from the bladder, or c o ffee- c o loured, as in stone

in the kidney ; it may b e largely increased in quantity by exertion or

shaking, jarringmo vements o f the body . AS before mentioned,in some

stages o f the c omplaint , the subjective symptom s are identical with tho seo f stone in no case

,therefo re, where tuberculo sis is suspected, can the

diagno sis o f the disease be c onfirmed until the non -existence o f s tonein the bladder be ascertained by physical exam ination , and until

,by

watching the progress o f events , the existence o f renal c alculus is negatived.

” He narrates the case o f a man,set. 35 , who se symptoms began

with pains in the back , fo llowed by irritability o f the bladder and frs

quent m icturition, w ith haematuria . After eighteen m onths,pain

c ommenced in the bo ttom o f the bladder, fo llowed by pain in the pen isand m o st acute pain in the glans

,espec ially just at the moment the

bladder was being emptied. The tenderness in the perinaeum was so

great that he c ould no t Sit. At this time the urine was blo ody,puru

lent, and full of mucus . No stone c ould be found. He died afterthree years Changes (detailed) were found in the kidneys

,ureters

,

bladder, and pro state. One patient was under o bservation many years .Ano ther

,a b oy, set. 45 , died in about four m onths . He had urinary

symptom s, and a tum our was felt below the right kidney . After deaththis was found to be

,probably

,due to a de o sit in the ureter. The

changes were in the kidneys . The case 0 a lad, set. 14, is no ted.

Sm ith calls attention to the s im ilarity between the symptoms and tho sein pulmonary m ischief. On the one hand

,suppuration ,

haemo ptysis,increased secretion o f mucus

, with the o c casional recurrence o f a spasm odic , expulsive,muscular effo rt (in the fo rm o f c ough) . On the o ther,suppuration, haematuria, increased secretion ofmucous

,with spasmodic


the bladder the stylet is rem o ved,and a bulbo us po rtio n projects in th

bladder . Lancet,

’No v. 9 ,

Vertebra ted, p ro s ta tic ca theter .

—Dr. Squire advo cates the use o f

s ilver catheter, the distal part Of wh ich is fo rmed o f jo ints . It isflexible and is adapted fo r cases o f enlarged pro state. A figu(‘Am . Journ . Med . Sc iences

,

’

O ct . 187 1 ,Dr. Sayre figures and describes his vertebra ted catheter and p ro

the ‘Brit . Med. July 2 2 , 187 1 . It is c ompo sed o f a nu

o f segments , is intro duced quite flexible and is then stiffened.

S tricture of the urethra—Mr. W . Stokes rec o rds a hundred casestreated either by gradual dilatatio n, external urethro tomy, internalurethro tomy

,o r fo rced dilatation . He thinks the fo rmer the m o st

satisfacto ry mo de Of treatment when po ssible. His mode o f perfo rm ingexternal urethro tomy was to pass a full-sized silver catheter down to thestricture, m ake a median inc is ion in the perinseum ,

'

reach the end o f the

catheter, feel the stricture, divide it car efully, and then having reachedthe dilated part o f the urethra pas s a flexible c atheter into the bladder.

In order to bring the catheter through the anterio r part o f the urethra ,Mr. Porter suggested the fo llowing plan . Take the ivo ry head o f the

flexible catheter away,pass a b ougie down the urethra

,bring it o ut at

the wound and fix it firmly into the catheter, and then withdraw the

bougie pulling the catheter with it . He has found internal urethro tomyvery suc cessful . He uses Mais onneuve’ s instrument . A filifo rm

flexible bougie is passed thro ugh the s tric ture, and pushed o n into thebladder carrying after it a curved, gro o ved directo r on which is passedthe cutting in strument, SO fashioned that the healthy urethra canno t becut, only the stric ture . He thinks this plan far preferable to forc iblerupture of the stricture . Cases are given and figures o f the ins trumentsemployed . Dub . Quart . Feb . 187 1 , I .)S tric ture of the urethra orchitis pycemic symp toms ; p erinea l sec

tion ; recovery—A man was admitted under Mr. Hulke

’

s care witho rchitis . He had repeated rigors a stricture was detected and perinealsection was perfo rmed. The man then did well . Lanc et

,

’No v. 9,

1872 )A case o f c omp licated s tric ture of the urethra treated by Mr. Syme

’s operatio n fo rimpermeab le urethra, is rec orded by Mr. Christopher Heath . Clin . S o c . iv,

Retentio n o f urine from imp as s ab le s tric ture, trea ted by fi lif’

o rm bougies . By W.

F . T eevan . Clin . S o c . iv, p .

Sir Henry Thomp s on contributes a second lecture to the Lancet(Dec . 7 , on s tricture of the urethra . He thinks Ho lt’ s o perationgenerally invo lves but little risk ; the benefit is no t very enduring.

He describes a plan intro duc ed by Dr. Co rradi and figures the instrum ent . Internal urethro tomy is said to give the best results o f any plan .

He prefers Civiale’ s in strum ent ; the inc ision Sho uld b e free . He has

p erfo rmed two hundred Operation s .

A new s tricture dilator .—Mr . BerkeleyHill des cribes a new stric ture

dilator . The two halves o f a Split sound, which in juxta -po s itio n equalthe c alibre o f a N o . 2 o r 3 c atheter, can be separated by thrustingbetween them a segment o f a c o ne fixed on a Slender stem . It is o f

ORcHITIs FROM PROSTATIC lNFLAIiIMATION . 273

c onstruction . Cases treated are narrated. Brit .t. 2 3 , 187 1 )a symp tom of retention of urine—Mr. Hutchinso n

writes on this po int and mentions cases . Brit . Med. Jan .

2 1 , 187 1 ,Persistent p riapism.

-See cases Bien . 1867-8, 3 1 7. Dr.

Mackie records the case o f a gentleman ,set. 70 . After much treatment

,

without effect, a free inc ision was made into the c o rpus caverno sum , c om

mencing at the c o rona glandis . Clo tted venous blo od escaped and

bleeding fo llowed ; the patient was relieved. T he acute symptom s hadlasted three weeks . E ffusion o f blo od into the structure o f the c orpus

caverno sum was finally suspec ted. The treatment was s o successfulthat the author recommends its early adoption in like cases . E din .

Med. Nov.

r Urinaryfistula of thep enis treated by urethrop lasty .

—Mr. JohnWo od

pub lisheSJa c linical lecture on this subject . Brit . Med. J

Aug. 2 4, See als o Mr. Pemberton ’s address on surgery Brit .

Med. Aug. 1 0,

and a no te by Mr. J . R . Lane on antescro tal , urinary fistula . Brit . Med. J Aug. 2 4,Ep ithelioma simulating bubo .

—At a meeting o f the K . K . Gessells chaft

der Aerzte in Vienna in January, 187 1 , Dr. Geber related the case o f a

man, set. 2 8, who had an epithel ioma in the right gro in . The patient

had excoriation after sexual c onnec tio n,which was fo llowed by en large

ment and induration o f the inguinal glands . Antisyphilitic treatm entwas employed, and it was only when this failed and the disease c on

tinued to Spread, that it was suspected that the case m ight be one Of

epithelioma . M icro sc0pic exam ination confirmed the latter Opinion .

Dr. Geber also related ano ther, sim ilar case,in which the differential

diagno sis between syphilis and epithelioma was attendedwith difficul ty ,and was on ly c leared up by m icro sco pic examination . (

‘Wiener M ed .

N o . 4 ,Orchitis from irrita tion in the p rosta tic ur ethra .

—In a c lin ical lectureon this subject

,Mr. Hutchinson details various cases in which o rchitis ,

term inating in suppuration and requiring inc is ion s, o c curred in c on

nexion with the passage o f pro static c atheters,litho trity

,litho tomy, &c .

It is rare in c onnection with litho tomy, o ccurring once in about fo rtycases . He then remarks

,these instances o f inflammation o f the testis

in asso c iation with some source o f irritation existing in the urethra, areo f great c linical interest . ” We may have (I ) inflammation of the vas

deferens only,as evidenced by deep -seated pain in the iliac fo ssa and

swelling in the inguinal canal . This may subs ide and the patient may

get well witho ut any further symptoms . ( 2 ) In connexion with inflamm ation o f the vas deferens an abscess m ay form o ver its c ourse, andmay require to b e opened through the abdom inal wall , o r may presentat the external ring. (3) T he inflammation may invo lve the who le vasdeferens and extend to that portion o f the testis which is directly c on

tinuous with it,viz . the epididym is , leaving the gland itself unaffected.

In a fourth gro up o f cases the ep ididymis , bo dy o f the testis itself, thetunica vaginalis , and the cellular tissue o f the scro tum are all invo lved .

In these cases the effusion is usually serum only and a speedy and com18


plete cure by absorption may be expected ; busuppuration may o c cur in the c avity o f the to thers

,still m o re exceptional, in the bo dy o f the t

a few cases the o pportunity o ccurs fo r Observinginflamed befo re the testis i s invo lved. (3) That 11inflammation begins and ends in an inflammation o f tgets to the testic le at all . (4) That ac c o rding to thesurgeons the o rchitis begins in the epididym is—i. s . in

Humphrey p o ints out, to the eflicient co un

o rchitis . Mr. Hutchinson agrees with Dr.

the discharge lingers the patient is liable tofo re, treats the discharge vigo rously in all

ment o f severe cases Mr. Hutchinson says , when the s in i sand when it persists in spite o f the use o f ice, I believe that theo f incision s is no t only safe, but very valuable. In slight casions

,if h armless

,are unnecessary . In cases in which ab

threatened an inc ision canno t be made to o early. A free

into the tunica vaginalis leads to no illthe inconvenience of suppurationout the pus the relief is immense.

albuginea into the testis itself do es no t lead to gangrene o f

no r always,even

, to fungous pro trusion . When the testis isappears to relieve pain

,much with the same c ertainty that i

does in acute glaucoma, and my impress ion is that it is likelycases to dim inish the danger o fgangrene on the one hand, and o f c on secutive atrophy on the o ther.

” Med. T imes and April 1 5 and 2 2,

1871 , 4 19 , Dr. Garden mentions in detail cases in which o rchitisfo llowed litho tomy in India . Med. Times and Jul y 2 9 , 187 1 ,

His proportion has been about one in fifty-two ; the left sideseem s m ore o ften affected, in c onnexion with the inc ision . In five out

o f sixteen c ases mentioned it is no ted that absces ses fo rmed.

E nlargement of thep ros ta te gland—Mr. Quain writes o n some forms

o f enlargement o f the pro state gland. In one case, a patient, set . 68,had very little trouble ifhe was careful to pass water frequently enough,

276 t oa‘r oN SURGERY .

Dr . Ashhurst reco rds a caseT he patient was a girl , set.

When lying down she couldshe was obliged to wear some po rtable receptacle.

had existed at the lower part o f the abdomen instsurface was now in a state o f healed c icatrix.

Am . Journ,Med. Sciences,’ July, 187 1 ,

Successful litho trity in a case of a tony of the Madden—Drjowsky o f Prague, relates in the Wien . Med.

and 19 , 187 1 , the case o f a gentleman ,one o f his c o lleagues in

versity, who‘

came under his care in O ctober, 1868,on account

in the bladder. The disease had been first detected in 1862,

bladder

and c o

i t was considereds o lved to practice litho trity, no twithstanding that itto b e attended with much danger when the bladderatony . The first Operation was perfo rmed in Oc to ber

,1868

,and the

litho trity was repeated at intervals on sixty-six subsequent o c casions,the last being on January 5th, 1870 . The bladder was each timewashed out by injecting water into it . The result was that the bladderwas freed from stone ; the patient reco vered from the ves ical catarrh ;and the urine became healthy . The atony, however, remained, demanding the habitual use o f the c atheter. Dr . Matiejowsky believes ,from an examination o f the fragments , that six calculi were broken upand remo ved. They c ontained a large quantity o f c arbonate o f limeand pho sphates o f lime and magnesia , and some uric ac id and mucus .Cho ice of op erations fo r s tone in the Madden—Sir Henry Thompson

has c ommunicated a clin ical lecture o n this subject to the ‘Lancet, ’July 2 2

,187 1 . He had had twelve cases recently in the wards . In

four he performed lith o tomy, in eight litho trity. All the patients reco vered. He thinks it m o st impo rtant to cho o se acc o rding to the cir

cum stances o f each case . It is unwise to cut all yo ur patients o r tocrush all the stones . In guiding your cho ice you must acquaint yo urselfwith—1 st

,the size Of the stone, or the amount o f the calculo us m atter

if multiple ; and,its c ompo sition : grd, the age and c on stitution o f the

patient 4th, the conditions Of the lo cal o rgans . A stone which mea

sures 1-1

1;to 1 -3 in . in its longest diameter is amenable to litho trity . A

stone o f which any diameter is 15} in. is mo stly to o large. For a smallstone, at whatever the age, lith o trity is the operation . E nlarged pro state rarely o ppo ses any Obstac le. Stricture Of the urethra should betreated first and then do es no t o ppo se any o b stacle . If litho tomy beperfo rmed, the lateral is always preferable. There were two childrenamongst the twelve patients . One who had a large stone was cut.

T he o ther had a small stone and this was crushed. It was ab out thesize o f an orange pip . Sir Henry uses a tube if there be haemorrhage .

The last case.

was that Of a man, ast. 72 , who was relieved Of a c on

s1derab le lithic ac id mass in eighteen sittings .High Op eration—Dr. P. H . Watson operated on an adult male by

LITHOTOMY . 277

o tomy. He could no t extract the stone . He then made a

c inc ision and removed the stone by that means . It weighedhalf ounces . T he patient recovered. E din . Med. J

set. 15 , Operated on byon the sixth day, and

Square. The bleeding cameLancet

,

’ May 1 1 , 1872 ,set. under the care o f the present c ompiler,

haemorrhage o c curred o n the fifth day. There had been no previouscomplication the bleeding came on quite suddenly

,after he had had a

vio lent fit o f passion and crying ; it was sO severe as to produce ratheralarm ing faintness , ceased as suddenly as it came on

,and did no t appa

rently hinder the child’s progress in any way .

Litho tomy .—A paper on I/itho tomg in India w ill be found in Dub . Quart. Journ .

’

(May, 1871 , by Dr. Curran. Four cases in wh i ch the stones were o f unusua l lglarge s ize are narrated by Mr. T eevan (

‘C lin . So c . iv, An analysis o f

s ta tis tics of la tera l litho tomy by Dr. Keith is c ontinued and c ompleted by the ac count

o f the fatal c ases in the ‘Brit . Med. S ept . 16 and 2 3 , 187 1 . Seven c ases are

recorded by Mr. E nsor, o f South Africa . Notw ith standing th e frequency o f haema

turia and o f renal calculi, ves ical c alculus is rare Lancet,’ Jan . 2 7. 1872 ,Professor E rich sen gives an interesting c lin ical lec ture o n s everal c ases on wh ich heOperated for rec urrent or multip le c a lculi March 18, 187 1 , A c linic allec ture o n l itho tomy, by Dr. E ben Watso n, is given in the ‘Lancet,’ May 4 , 1872of 4 7 patients operated on by him two on ly died ; h e uses Buchanan ’

s rectangularstaff. A c linical lec ture, by Pro fes sor Humphrey, is g iven in the Lancet, ’ June 1 ,

1872 , and one by Mr. Forster on l ith otomy and lith o trity in the ‘Lancet, ’ Oct. 2 6,1872 .

Rup ture of the fema le Madden—W . Stokes , 111 a c linical lecture on

rupture o f the female bladder, says he c ould only find no tes Of fivecases (in Mr. Ho iiel

’

s mem o ir) . Two o thers o ccurred under the care

o f c o lleagues o f his own ,and he adds one case . The patient survived

six days and fifteen hours . The rupture was at the anterio r part o f thefundus . He discusses the diagno sis . He mentions two cases

,rec orded

o f reco very after rupture o f the male bladder. Brit . Med. Journ .,

March 2 3 ,Wo zmd of the bladder in fracture of the p elvis ; recovery .

—Dr. Bellshowed a lad who hadfractured his pelvis . Whenhe came under care hec ould only pass water through a wound on the left side o f the abdomen .

A probe went straight into the bladder . NO catheter could b e passed.

This was at last acc omplished. NO m ore urine came through the fistulaand the latter healed. Ano ther case was mentioned where the fistulawas on the o ther side . (E din . Med. J O ct .

I/ithotomg ; remova l of a p iece of bone from the Madden—SirHenryThompson rec ords the case o f a patient on whom he operated fo r stonein the bladder, and remo ved a calculus which pro ved to be bone en

crusted with pho sphates . T he patient was a lad fifteen years Of age.

Fo ur years previously he had been run o ver by a cart . On prelim inaryexamination with a litho trite a p iece o f bone was remo ved, and at theOperation a larger piece was found. A somewhat sim ilar case, in a man

,

a t. 40, o ccurred seven years before. Sir Henry removed fragments of


b one and pho sphatic matter by litho trity . T he bone had pronecro sed from the o s innom inatum as the man had had abscessesthe hip . Figures are given and allus ion is made to the o therreco rded . Lancet, ’ June 2 2

,1 872 ,

Ca lculus nesiote in the fema le,—Dr. Watson remo ved a calc ulusweighing 1 1 2 0 grains from the bladder Of an elderly woman by rapiddilatation . She was able to retain her urine within twenty-four hourso f the operation . E din . Med. Journ .

,187 1 , 6 Dr. Atlee remo ved

a stone weighing 2 2 0 grains , andmeasuring 3 35 th inches , in its greatestc ircumference, and 2

T°

3ths

,in its smallest, from the bladder o f a female

,

wt. 73 , by rapid dilatation Of the urethra . He usedHo lt’s dilator and a

p air o f dressing fo rceps . The patient had no inc o ntinence o f urine .

Am . Journ . o f Med. S c iences, ’ April 187 1 , Dr. Long remo veda large stone from the bladder o f a female

,set . 33, by rapid dilatation .

In c ontinence resulted fo r three days . The stone weighed 308 grains,was four and a half inches in its longest and three in its sho rtest cir

cumference .

A translation o f the repo rts o f two cases recorded in the Ho sp ita ls

T idende in which ves ico -vaginal litho tomy was perfo rmed,is given by

Dr. Mo ore in the Dub . Jo urn . Med. April 187 2 , 353 . T he firstpatient was thirty-five years Of age ; symptoms had existed fo r fiveyears . A “ large ” stone was detec ted. Litho tomy was first attempted,but owing to the hardness o f the stone and the pain caused was unenecessful . Guérin

’

s o ld apparatus fo r lateral litho tomywas used (instead o f

a round o r straight directo r, passed along the urethra) to guide theknife in inc is ing thevaginal wall . The stone was eas ily rem o ved. An

hour later the wound was united with ten silver wire sutures, whichwere fixed with leaden plates . The urine was drawn o ff every seco nd o r

third hour. On the seventh day, five o f the sutures were remo ved.

The wound was healed. On the twelfth day the w ires were rem oved.

NO aperture whatever remained. The o ther patient was 3 2 years o fage . The stone was o f a to lerably large s ize .

” It was found impo s sible to crush it . The female blade Of the l itho trite was employedas a directo r. After three quarters Of an ho ur had elapsed the wo undwas c lo sed with eleven sutures (s ilver wire) , which were twisted. Acatheter was inserted. T he vagina was washed out regularly On the

third day catheterisationat regular intervals was adopted. On the ninthday three sutures, and on the eleventh one, and on the fo urteenth daythe o ther seven were remo ved. N0 gap remained. The nucleus o f

the stone c ould no t be crushed with the h tho trite out o f the bo dy,only

the outside crust . In the first case the stone had been crushed intotwo parts by the litho trite . Together they weighed grains . Thelength was six centimetres in ) , the breadth five centimetres (2 '

o

and the thickness two centimetres '8 The seco nd calculus waso ne inch and a half in its longest diameter, and one and a third andone inch in o thers . Its weight was 2 54 63 grains .Recta l lithotomy .

—In the ‘V ierteljahrschrift fur die prakt. Heilkunde, ’ iii, 1872 , Th . Schader des crl bes two metho ds o f perfo rm inglitho tomy through the rectum . He uses fo r dilatation specula likeSims

’

s, but adapted to the rectum . T he o perations which he describes


days after the Operation . The sto nes weighed, together, 9 °

( 146% grains) . They were, like the fo rmer one, fo rmed

nuclei fo llowed by two layers o f earthy ph o sphate and one Of

The third case was that o f a b oy . act. 7, who three years

Phe became very restless at night,s trained, and endeavour, but in vain ,

to pass urine. The next morninghe would have no rec o llec tion o f what had o ccurred. He had alsovio lent itching o ver the who le bo dy, which was repo rted to then havea bronze c o lour. In the daytime bright c o loured urine was frequentlypassed in small quantities . In the summ er his c ondition improved ; butin the winter Of 1863 , irritation Of the extrem ity o f the penis set in .

His urine when exam ined in March , 1864, was fo und to be strawc o lo ured, slightly turbid, Of acid reaction , and to depo sit a sedimentcontaining hexagonal plates of cystine. This

,however

,was no t found

in the sediment on subsequent exam inations . During the summer heagain improved but in the winter the symptom s became m o re severe ;his fseces were frequently m ixed with mucus and blo od ; there werealternate suppression and incontinence Of urine ; and he was takeninto ho spital in Ma 1865 . On the day after his adm ission, Dr. von

Dumreicher remo ved:by the lateral Operation ,a sto ne about an inch in

diameter,weighing abo ut ten grammes grains) and consisting

entirely o f cystine . The Operation was fo llowed by a severe attack o fcystitis and pericystitis, which , however, was subdued in the c ourse Of

ten days by inunction o f mercurial o intment into the abdomen and

warm applications . The urine passed partly through the urethra on

the fifteenth day ; and the patient was discharged, cured, four weeksafter the o peration . The fourth patient was a man

, act. 35, who wasadm itted into ho spital in N o vember

,1870 , having suffered for two years

from pain in the bladder and o ther symptoms o f stone ; fo rnine m onthshe had had c onstant dribbling o f urine . None o f his fam ily wereknown to have suffered from calculus . The patient was thin

,and his

skin was almo st bronze-c o loured. The liver was no t enlarged, no r

was there pain in the hepatic region . On sounding, a hard body,which c ould no t be pushed into the bladder, was felt in the pro staticp ortion Of the urethra . It did no t give a very clear sound on

being struck, and its surface was felt to be rough ; a small portionwhich fo llowed the remo va l o f the sound

,was , on examination, fo und

to consist of cystine. The urine was o f ac id reaction,o f Spec . grav. 1007

it was c loudy and yielded a flo cculent sediment o f pus, together withep ithelial cells from the pelvis Of the kidney and casts from the tubeso f Bell ini . T he quantity o f c o louring matter and uric ac id in theurine was much dim inished the urea and salts were in norma l amount ;and there was a go od deal o f albumen . There was no cystine inthe sediment . The median Operation Of litho tomy was performed on

N o vember 1 7th , and the stone was remo ved in three pieces witha quantity of detritus ; the who le was calculated to weigh fortyfive grammes (694—3 grains) . The patient went on well for some days

TE STICLE IN THE PERINAL‘

UM. 281

but, on November 30th febrile symptom s appeared ; diarrhoea set info ur days afterwards ; and he died on December 1 2 th . The cause Ofdeath, as far as the necrop sy gave any indication, was general anaemiaand hypo static pneumonia . There was some disease o f the parenchymaof the kidneys which had apparently c ome on subsequently to the Ope

ration, and did no t seem suffic ient to account fo r death . T he suprarenal capsules were healthy, s o that the bronzed state o f the patient ’sskin was no t c onnected with disea se Of these structures .Treatment of tuberculous testicle by the actua l cautery .

—M . Verneuil,

in a c ommunicatio n to the Surgical So ciety o f Paris , expresses his preference fo r the ac tual cautery o ver all o ther metho ds o f treatment o ftuberculous testis . He introduces c onical

,o r Olive-shaped cauteries

into the fistulo us o penings, penetrating the indurated scro tal tissue,and destroying the diseased structure o f the testicle. Under this treatment

,he says , patients are enabled to leave the ho spital in a few weeks .

The constitutional disease, however, is not eradicated, and the diseaseis likely to return in the testis, and extend to the pro state . Cauteriza.

tion ,however

,relieves the patient fo r a year o r two , and appears to

delay the recurrence Of the disease. In the discussion on M . Verneuil ’sc ommun ication ,

M . Legouest expressed an o pinion in favour Of castration being perfo rmed much more frequently than it is in such cases,and at an early period of the disease. Gaz . Med. de Paris,’ November 4 ,

Testic le remo ved f or neura lg ia—Mr. Annandale showed a spec imen . T he pain

had existed for six or seven years . NO disease was found except s light th ickening ofthe ep ididym is E din . Med. J Sept. ,

Cancer of an imp erf ec tly descended testis ; difiicultg of diagno sis .—Mr. HenryArnott, Path . xxii, 182 .

Transition of the testic le into the p erinceum.—Mr. James Adams

narrates the case o f a male infant,aged eleven weeks , wh o came under

his care fo r a m isplaced testis . The right side Of the scro tum was nor

mal . On the left side was a pouch , but no testis in it . The left testic leformed a smo o th o val swelling in the perinaeum ,

to the left Of the m iddleline , and half an inch in front of the anus . It was quite m o vable. The

co rd c ould not be felt owing to a c onsiderable thickness Of fat. Mr.

Adam s operated by making an inc ision about an inch and a half long,

from the external abdominal ring o ver the empty scro tal pouch , whichhe carefully o pened, thus preparing a bed for the testic le . He then feltfor the c ord, and having found it, fo llowed it down to the testis, takingcare no t to injure the tunica vaginalis . On making traction on the co rd,it became evident that there was some firm adhesion between the lowerpart o f the testic le and the perineal pouch . This, Mr. Carling sug

gested, was the gubernaculum . Mr . Adam s dissected down to itsattachment, and divided it as far from the testis as po ssible. The testiswas then raised, in its uninjured tunica vaginalis, and p laced in the

scro tal pouch . A catgut suture was passed through the gubernaculumand fixed to the bo ttom of the scro tum . On the third day the edges o fthe wound becam e sloughy, erysipelas fo llowed, and the child died at

the end o f a fortnight, apparently o f exhaustion . Reference i s madeto the o ther two cases on record, and Mr. Adams remarks, the chief


arguments a

scro tum willa few years it will2 . That, as nearlyphied, there is a chbeen asserted thatis liable to injury.

T he gland, howevecase

must alm o st necessarily bo f the pro bability o f the po tency o f the serous mem brane ; and, secondly,because the malpo sition may no t pro ve to be o f any inconvenience,unless the patient is destined to become an equestrian .

May 2 7 , 187 1 ,T reatment of gonorrhcea l ep ididymitis 6g ice.

—Dr . Bo rgioni, in a.

paper published in L’Imparziale,

’

fo rMay 1 and 16, 1872 , rela te s fo urc ases Of gono rrhoeal ep ididym itis treated successfully by ice. He does

no t bring forward the remedy as new, no r do es he c onsider the numbero f his cases suffic ient to warrant his saying that it is always eflicacious ;but, as far as he can judge, he believes it simple o f application

,and

capable Of effec ting an early cure.

Gonorrhcea l or urethra l rheumatism—Dr. Bondwrites on this subject.He c onc ludes with the fo llowing deductions, that urethral rheumatismis a slow fo rm Of pyaem ia p o isoning, due, not to a sudden absorption ,

b ut to a gradual vitiation o f the blo od by progressive abso rption Of theurethral discharge ; that the vitiated state i s no t maintained independently o f the lo cal di sease ; that when the discharge is tho ro ughly andpermanently stepped, the rheumatism may so on be cured and has no

tendency to return ,except by the access of a fresh urethral discharge .

Lancet,

’ March 2 3 , 1872 ,Vesico -vagina l fi stula—Dr. Jo seph Bell reco rds cases on which he

has Operated successfully . He uses a series o f steel p o ints, highlytempered and curved, in various sizes, some no t larger than one thirdo f the c ircumference o f a S ixpence

,o thers bearing the same proportion

to a shilling, but all welded to the silver wire in such a manner as to

project no shoulder, and require no threading. These are easilymanagedeither with a Sim s’ needle fo rceps , o r by an o rdinary pair o f dressingfo rceps , and setting the wire at a right angle to the needle and curvingit ro und the hand and arm, it is readily m anaged with great ease . He

also finds (Sim s’ barbed ho oks of great service. Edin. Med. Journ .

’

Jan . 187 2 ,Imp erfora te hymen—A case in which Dr. Barton o perated succ ess

fully fo r retained menses, owing to an imperfo rate hymen i s rec o rded.

Dub . Quart . Journ .

’

Feb . 187 1 , The patient was fifteenyears o f age . The septum acro ss the vagina was divided carefully, andno t very freely . It was o f c onsiderable thickness . Reunion partiallyo c curred, but was obviated by retention of a piece of Oiled lint.


mode Of incision recommended -by Mac leod, o f G lasgow, combined witha novel mode o f using the écraseur. He made the incision by thrustinghis knife through the cheek in front o f the ramus Of the jaw,

and thencutting towards the angle Of the m outh. T he vessels were secured bytorsion . He thus Obtained free ac cess to the ro o t o f the tongue .

“ T he

tongue was then seized c lo se to its ro o t between the finger and thumbOf one hand, while the o ther carried under the tongue a strong curvedneedle, threaded with four pieces Of ligature . These drew back thro ughthe channel made by the needle the chains o f two écraseurs

,one after

the o ther . One was fixed so as to divide the tong ue near the larynx,

the o ther was to separate it from the flo or o f the m outh . The instru

ments were worked simultaneously , and in about seventeen m inutesc lean rem o val was effected, abso lutely without haemo rrhage. Lancet

,

’

April 2 0,1872 ,

Mr. Annandale rem oved the right ha lf of a woman’

s to ngue by Buchanan ’s m odi

fication of Sym e’s Operation . T he patient w as 7 1 years o f age. At time o f no te she

was 72 , and there was no recurrence Edin . Med . J Aug , 1872 , A suc

cessful c ase in a w oman , aged 62 , under the care o f Mr. Canton , is noted in the

Lancet ’ (Jan . 2 0, 1872 , T he tongue was drawn down below the maxilla, anddivided by an éc raseur. Mr. Lee rec ords a case. He divided the jaw , and passed

l igatures , in a spec ial manner, through the b ase Of th e tongue b efo re cutting it away.

NO h aem orrhage o c curred. T he patient recovered . Clin . S o c . iv, 1

Abs ces s of the T ongue—Dr. Po o ley records a case o f ab scess of the tongue in a

girl seven years Old Am . Journ. Med. April , 1872 ,Congenita l hyp ertrop hy of the tongue

—A case was shown to the

Clin ical So ciety by Mr . Lawson . v,

In a case under the care o f Mr . S imon remova l of p ortions with theécraseurwas practised and death fo llowed . Repo rt o f the case by Mr.

Arn o tt . Path . xxiii,In a case o f congenita l hypertrophy o f the tongue which came under

the care Of Mr. Fairlie C larke he us ed the écraseur with suc cess . The

patient was . four m onths o ld. The pro truding po rtion only was re

m o ved. Lancet,

’March 30 , 1872 , 433 , and Path . xxiii, 1 1

Fatty masses in a ranula—adip o cere.

—In a case Of apparently o rdinaryranula

,Mr. Waren Tay evacuated five masses

,like lumps o f firm butter,

from a cyst under the tongue . Dr. Tidy pronounced them,from che

m ical exam ination, probably in the c ondition o f adipo cere . They wereno t o rdinary fat. Path . xxii

,

Afattg tumour raider the tongue resembling ranula is recorded byMr. Churchil l who gives a resumé o f o ther cases . Path . xx

,

iii,F ibrous tumour of the tongue

—Dr. Po o ley records the case o f a

young woman (set. 2 who came under his care for a tumo ur o f the

tongue o f twelve months ’ duration . It was hard to the touch , andplaced far back . It had a broad base . Bleeding o ccurred o c casionally. It was rem oved with wire écraseur with some difficulty owing toits density. There was no bleeding. The patient so on rec o vered.

After rem o val the tum our was as large as a bantam ’s egg perfec tlySpherical in form, with a pedic le an inch in diameter, had severa l stellatecracks o r fissures extending through the mucous membrane with whichit was covered, which were undoubtedly the source of the repeated hse

SPASMODIO STRIOTU'

RE OF THE (E SOPHAGUS . 285

s . In structure it was a firm fibro id and resembled accurately,

also in its symptom s , the well-known fibro id p o lyp i Of theOne case is quo ted from Paget, ano ther from Co oper

’sone , from Bo ston Med. Surg. J all the autho rpatients were youngmen . Am . Jo urn . Med.

872 , Dr. T itts reco rds the case o f a woman, set. 30 .

ining her throat and while depressing the tongue he no ticed a

ris ing up at its base, o f about the size Of a filbert . It wasin the median line

,s o far back that it was difi cult to pass the

finger behind it . It was exceedingly hard, inc ompressible and im

moveable. It was not apparently pedunculated. In a few m onths thegrowth steadily increased in size, and almo st filled the who le o f the

fauces . Pro f. Bigelow Operated. He remo ved the tumour with theécraseur. It was pronounced fibrous or fibre -recurrent . At the end o ftwo years there was no recurrence . Am . Journ . Med. July,

Hysteric or spasmodic s tricture of the oesop hagus .—Sir James Paget

considers this c ondition the homo logue, in the pharynx o r oesophagus,o f that want o f harmony between the o rgans o f Speech and respirationwhich produces stammering and appears to depend on a want o f perfeet c oncert between certain invo luntary muscles and musc les actingunder the c ontro l Of the will which are designed to act in harmony .

In the latter case the musc les Of respiration do no t act in time and

un ison with the o rgans Of speech in the former,instead o f the normal

c ontraction o f successive po rtions Of the upper part Of the alimentarycanal from ab ove downwards which transmits the fo od regularly fromthe m outh to the stomach

,there o ccurs an unruly c ontraction Of certain

fibres which, as long as it c ontinues, bars the passage o f fo od as com

pletely as if some permanent o bstruction existed . The degree o f thisc ontraction varies in different cases ; in some it only c om pels thepatient to take his m eals apart o r inconveniences him whenever hisattention is in any way directed to the act Of swallowing : while, ino thers

,it pro duces c ontraction so Obstinate and comp lete that the

maintenance o f life by means o f gastric digestion is who lly prevented.

In these cases recourse must be had to enemata,and it will be found

necessary to m ake use o f something m ore than beef tea and brandy ,and by injecting preparation s c ontaining fats , starches, sugars, and

vegetable as well as m eat juices, to supply all the ingredients whichare c ontained in a natural diet, and are essential to the building up o f

the various tissues o f the bo dy. Of the fact that vegetable juicesc o ul d thus be effectually intro duced into the system ,

he had recentlyhad very satisfacto ry pro of in the case of a patient with who se nutritiveenemata some o f the essence Of water cresses prop o sed by Mr. Wyatthad been intro duced . At the end o f a few days the patient had beggedthat the quantity o f the essence m ight be dim inished, because theflavour o f the vegetable in his m outh had become so strong and so constant as to be extrem ely disagreeable. Lancet, ’ Jan .7, 187 1 ,Resection of the cesop hagus .

—Tu an artic le in the Archiv fur Klin .

Chirurg.

’

(Band xiii , 6 Dr . Billro th suggests that this operation maybe found practicable in cases of cancer o f the oesophagus . He remarks

286 REPORT ON SURGERY.

that the disease is generally limited to one part, and that attemptsdilatation o ften only increase the evil by tending to ulceration .

suggests that a fter rem o ving if the canc er

situated sufliciently high) , the rtension by bougies and thatto that which takes placeth is canal by u lceration,

s

ro th remo ved an inch and a quarter o f the oesophagus, and unitedlower end o f the tube to the skin by two sutures , s o as to allowintroduction Of a tube through which m ilk was to be co nveyed intostomach . On the fifth day, it was fo und po ssible to intro duce a tubethrough the month ; at first it had to b e guided along the wo und bym eans o f the finger, but afterwards this becam e unnecessary . T he

sutures were rem o ved a week after the o peration . There was at first agreat discharge o f mucus through the wo und ; this gradual ly decreased,the Opening became smaller, and in two m onths en tirely c lo sed ; andan (e sophageal b ougie o f the size o f a large index finger c o uld bereadily pas sed. T he dog was fed with meat

, p o tato es , &c .

, and thro vewell . A little m ore than twothe c icatrix was fo und to b e annular,readily distensible .

Fo reign bodies imp acted in s tricture

Dr. Menzel relates, in the ‘Archiv fuc ases o f two children,

patients in the

whom stricture o f the oesophagus had been pro duced by swallowingirritant fluids , and in whom also fo reign bo dies subsequently becameimpacted in the stric tured po rtion . T he firs t patient was a b oy aged

6,who

,a year previous ly, had swallowed some strong lye, in c onse

quence o f which great narrowing o f the oesophagus o c curred. He was

bro ught into ho spital o n acc ount o f having swallowed a breeches button .

Dr. Billro th remo ved this by (Jo sephago tomy, and the patient was discharged, with the external wound healed, o u the twenty-firs t day after

the operation . The sec ond patient, a girl, had strictured oesophagus ,the result o f swallowing n itric ac id, and was unable to swallow so lidfo o d. She was brought to the ho spital o n ac count o f having been fo rten days unable to take any fo o d whatever through the m onth . Aslender oesophageal tube, however, was pas sed, through which somem ilk was introduced. After this

,the c ondition varied ; sometimes

deglutition was to lerably easy,s ometimes quite impo ss ible ; on some

o c casions a b ougie o f m o derate s ize c ould be passed, while o n o thers thisc ould not be done, and it o c casionally seemed a s if a fo reign bo dy werestruck, though this could no t be distinctly made out. The ch ildgraduallylo st strength , became feverish , and died on the fo rty-eighth day after

adm ission . At the necropsy, there was fo und in the oesophagus a semilunar aperture leading into a cavity in the submuc o us tissue, in whichlay a blue glass bead, o f the s ize o f a pea . A narrow

,fistulous c anal led

from the bo ttom o f the cavity to a c o llection o f pus in the mediastinum .

There was also purulent effus ion in the right pleural cavity . Dr. Péan

relates in the ‘Tribune Médicale, ’ January 2 1,1872 , the case o f a b oy,

aged 8, who had a peach -stone impacted in the oesophag us beneath the


l igature passed round this smal l branch at o nce stayed the bleeding.

The margin s o f the wound were freely touched with tincture o f muriateo f iron, and the edges o f the wo und in the neck were brought togetherwith sutures . The patient was fed by a tube. The wo und became unhealthy lo oking, slight haem o rrhage o ccurred, checked by iron . T he

patient gradually became weaker, and died n ine days after the Operation .

No p o st-mortem was allowed. Mr. Annandale remarks, “ The histo ry

o f the case, the detection o f the fo reign bo dy by means o f the probang,and the condition determined at the o peration are, I think , suffic ientpro of that a sharp fragment o f bone had lo dged in the (e sophagus , andwounded its walls . This wound had been fo llowed by ulceration

,

which,in its progress, had invo lved the arterial branch and caused the

haem orrhage . It seem s probable that my first intro duc tion o f the

proban'

g'

displaced the bone, and that this acc ounted fo r the relief o f

the symptom s and the disappearance o f the inflammato ry swelling inthe neck . Had the bone remained in its o riginal po sition , an absces s ,po inting externally, would have been the result . From the fac t thatno difficulty in swallowing was experienc ed after the intro duction of

the probang, it is likely that the b one passed down into the stomach .

Had I not po ssessed a c lear histo ry Of this case, and had I no t also distinctly felt the bone and ascertained its po s ition

,o perative interference

would scarcely have been justifiable ; for although the blo o d was evidently com ing from the pharynx o r oeso phagus , it was impo s sible to becertain as to its exact source .

”The disc o very that the wounded vessel

was n o t a branch Of the caro tid,but Of the subc lavian artery

,is an ex

cellent, but, at the same time, rare illustration o f the impo rtant princ iple in the treatment Of wounded arteries

,namely

,to search fo r the

bleeding-po int itself and secure it , if po ssible. Ligature o f the caro tidartery, in this case, could have had no influence in restraining thehaemorrhage from the bleeding vessel . ” T he progress o f the case, fo r

the first few days , was all that could be desired. The fac t that thepatient had been hemip legic for some time on the left side

,and was no t

in a go od state Of health, tended to dim inish her chance o f rec o very .

The bleeding after the operation was only from the sloughy edges o f thewound in the neck, no t from the oesophagus , and blo od never came bythe mouth . Edin . Med. J April, 1872 ,Radic a l Cure of Inguina l Hernia—Professo r Fayrer records cases Med . Times

and April 6,Hernio tomy.

-Mr. E richsen o perated on a ma le infant, aged s ix weehsfor strangulated inguinal hernia . T he child recovered from the Operation,

but died a month la ter from pleurisy and periton itis . Lancet,

’

May 18, Mr . J . D . Hill performed hernio tomy in a case of

c ongenital scro tal hernia in an infant eighteen months o ld. Strangulation had existed twent -four hours . T he sa c was no t opened . The

baby reco vered. (‘Me Times . and April 8

,1871 ,

Sir James Paget has co ntributed Clinical Lectures o n S trangula ted Hernia to theBrit. Med. J i and i i, 187 2 .

Direc t Inguina l Hernia in the Fema le—Mr. Squire, Path . xxn , 148.

S trangula ted Femo ra l Hernia , reduc tio n in ma sse .—c orted by Mr. Mo rris ,

under the care o fMr . Lawson. Path . xxi i,

290 REPORT oN SURGERY .

rec overy,the only disturbance o f any kind

testis in c on sequence o f the pres sure to whM . Demarquay says that the treatm ent o f

dicated in the fo llowing c irc um stan ces — 1 .

o r in recent herniae whio f their formatio n ; 2

,i

few days befo re strangul

large, umbilical hern iae. T he operation ,he says , should

o nly at an early perio d, when there is reason to believe thattine has n ot yet undergone any destructive change . Bul

de 13 ,

Mr . Jessop says , “ I remember the late Mr. Teale, in 1

intro duc ing an acupuncture needle twenty o r thirty timesabdom inal walls in a case o f excess ive tympany fo llowingremarking to the students around him that

,in his

been ac customed,under s im ilar c ircum stances

,

the m anner o f veterinary surgeons but that,o f

ferred the acupunc ture needle as being at the

and equally effic ient . ” Mr. Jes so p has u sed

facto ry resul ts on several o ccasions . Brit . Med. J Dec . 7D iap hragmatic hernia .

—Dr. A . Po pp, in the Deutsche ZeitsBand i, has co llec ted fo rty-two cases o f diaphragmatic

adding two Observed by him self. He arrives at the fo l lowing

sidecausesthree falls in ten ; and inertion , a fall with a vio leby a c arriage . In m o st cases

,the hernia was fo rmed o f the st

transverse c o lon,o r a po rtion o f the omentum . In five ca ses , the

was in the right p leural cavity, in thirty-two , in the left . Tgno sis i s difi cult

, but may be aided by the histo ry o f the case and byaus cultation and percussion .

J . Sargent relates a case o f diaphragmatic hernia in the ‘Bo stonMed. Surg . Journal ’ fo r February 2 2

,1872 . In 185 1 , a woman ,

named S was injured by the handle o f a hay-fo rk

,which entered the

vagina and bro ke the first rib on the left side . She rec o vered,and died

in 187 1 o f peritonitis . At the necropsy, the left pleural c avity wasfound to contain , bes ides the c ompressed lung, the stomach , the transverse c o lon,

several inches o f the descending c o lon,and a c onsiderable

po rtion o f the small intestine. In the left half o f the diaphragm was

an irregular Opening four inches in diameter .Obturator hernia .

—Dr. Chiene describes the co nditions found by himin the bo dy o f a wom an

, set. 73 , in the dissecting ro om . On o pening theabdomen , a p o rtion o f the ileum was found strangulated in the openingat the upper part o f the Obturato r fo ram en . On dissec ting downwards, am o ng the adducto r musc les o f the thigh , a sac , the size of a

pigeon’ s egg, was expo sed. It was brought fully into view by cutting

I

292 REPORT on SURGERi‘

.

with o ther malfo rm ations of the gen ital o rgans . Tho se cases o f ohernia which c om e on at a later p erio d o f life must b e ac c ountedsome such c onditions as exces sive length o f the o varian ligament,ing fo rward o f the uteru

o r the drawing down 0

herniae,the o vary and

a cquired hernia usually

Ovarian hernias are generally pebeing very narrow, espec ially whetion . In the fem o ral fo rm , the

any info rmation as to diagno sisc on sistence o f the swelling. Itthat the pain produc ednumber o f cases in c ludo rgans . The healthy

dragging o n the

that o f the herniinc lined towardsmenstruation are

gno sis . In some

the patient feels pain in the

m any cases there have beening even skilful surgeons into the erro r 0

deal with strangulation . In one case,in

the changes in the hernia at the men strualthis c ondition . Inflammation o f o varianm ay a c c ompany m enstruatio n . E nglis ch o bserves that even in omentaland intestinal hernia the period o f strangulation o ften c o inc ides withthat o f menstruation and he believes that the c ongestion ,

which affectsno t o nly the o vary but the peritoneum

,may in c ertain cases give rise

to the phenomena o f incarceration . When an o vary that has undergone cystic degeneration bec omes gangrenous, it may readily be c on

founded with gangrenous intestine . The vom iting which o ften aecom

panic s inflammation of a disp laced o vary,is ascribed by E nglisch to

a sympathetic affection o f the intestine,and no t, a s has been supp o sed

by Miilert, to c om p ression o f the intestine against the o verstretchededge o f the bro ad ligament . In inflammation o f an o varian hernia,the abdom en is usually les s distended

, and the c ountenance less anxiousthan in ordinary strangulated hern ia . When an o varian hernia suppurates, the absces s very rarely bursts into the abdomen. When therei s strangulated intestine, at the same time with the o vary, in the hernia,the symptoms are increased in severity . The condition o f the sto o ls

SCIATIC HERNIA—INTESTINAL OBSTRUCTION .

certain aid in the diagno sis ; which , however, is Oftentwenty cases in which symptomsfo f incarceration werediagno s is was fo rmed in seven only in the remainder

,

hernial c ontents was n o t ascertained until the sac

T he progno sis in o varian hernia is favorable as re

Of the organ .

p o ssible, byf the herniatumo ur be

c ome very painful, extirpation i s indicated. When inflammation o ccurs,

the patient must rest ; c o ld applications are to be used in the traumatic , and warm in the menstrual form . If absces s o c cur

,it sho uld be

opened o r it may be evacuated by means o f an aspirator. The Openingo f the peritoneal sac for the purpo se o f replac ing an irreduc ible healthyo vary is c ondemned by E nglisch . O f the cases in wh ich extirpationo f a healthy irreduc ible o vary was performed, one half died o f sub

peritoneal inflammation and its results .

S ciatic hernia —Dr . Marzo lo o f Padua has described the case of a

female who was first seen by him in 1847 . She was then thirty yearsOld, and fo r ten years had no ticed a small tum our in the right glutealfo ld, which disappeared o n lying down ,

and again pro truded and gra

dually increased while she was erect . T he patient had been pregnantfive times ; On fo ur o ccasio n s she m iscarried

,and o nce bo re a healthy

child at the full term . The hernia now fo rmed a large swelling, thebase o f which c overed part o f the nates

,and reached a s far as the tro

chanter and the pubic arch . It was 60 centimetres in length , and 1 18

in its greatest and 80 in its smallest c ircumferen ce. It apparently c ontained a large part o f the intestines , as the belly was retracted, theabdom inal wall lying in c ontac t with the vertebral c o lumn . On lyingdown o r sitting, m o st o f the hernial c ontents returned into the abdo

men,the patient was ac customed to sit upo n the hernia . Defaecation

and c o itus were interfered with . The patient came under treatmentagain in 187 1 . There was n o great change in her c ondition ; b ut thehernia had now bec ome quite irreduc ible, and at the lower part the perca ss ion so und was dull and fluctuation was distinctly felt . Marz o lonow made a puncture and drew o ff n ine quarts o f fluid ; severe diarrhoea s o on set in ,

and the patient died. A p o st-mortem examinationcould no t b e made . (

‘Wien . Med. July 6,Intes tina l obs truction injection kneading cure—Dr . Hilton Fagge

records the case o f a man,set . 40 , wh o was attacked w ith great pain in

the abdomen quickly fo llowed by severe vom iting. This was O ct . 2 2,

187 1 , in the evening . He came under the care o f Mr. Bro okhouseO ct . 2 3 . His face had an anxious expres sion ; he was crying out withpain

,a little to the right o f the median line o f the epigastric region ,

increased by pressure . On the fourth day Dr. Fagge saw him . The

vomited matters were no t sterco raceous . On O ct . 2 8,the seventh day,

in the even ing (that is after six days ’ strangulation ,ac c ording to the

dates given, but five days ac co rding to the heading) , a c opious injec tion was given and the abdomen was kneaded. The injection wasrepeated next day. The man reco vered. Dr. Hilton Fagge remarks ;


In this,as in so many o ther cases o f intestinal Obstruction ,

itno t po ssible to determine accurately the cause o f the disease.

h istory o f the attack po inted to a sudden c lo sure o f the calibre o fb owel

,and pro bably to the small intestine as its seat ; while the

m anipulation o f the abdomen would, in m any instances,invo lve great

risks o f tearing through parts softened by inflammation, o r evensloughing, and m ight thus c ounterac t the curative pro cesses o f nature .

It can scarcely b e said that there was anything in the symptoms inMr.

Bro okho use’s case that indicated the spec ial applicability o f kneadingn o r do es the suc cess o f the treatment enable a m ore accurate diagno s isas to the nature o f the intestinal lesion to b e given than had been givenbefo re it was tried. The case still remains very obscure in this respec t . ”Lancet,’ July 2 7 , 1872 , 1 A case is reco rded which came under

the care o fMr.Waren T ay, at the LondonHo spital . A man,set . 49 ,

who

was apparently in go o d health , was seized while in the street, at five

o’

c lo ck in the m orning, with acute pain in the epigastrium . He so onvom ited and c ontinued to do s o . Thirty-six hours later the vom itingbecame sterco raceous , and seven o r eight hours later he was admitted.

He c ontinued to vom it sterco raceous matter repeatedly ; he was in greatpain (referred to the right s ide and abo ve the umbilicus) , and appa

rently in an urgent c ondition o f c o llapse . N o hernia c o uld b e asoertained. There was no lo cal swelling o r tendernes s to aid in the

fo rmation Of an ac curate diagno s is . There was no history of any previons attack Of any sort . Some sudden displacement o r kno tting o f

intestine seemed indicated. The man’ s symptom s were s o urgent that

the question o f gastro tomy had been enterta ined. It was no t thoughthe wo uld live thro ugh the night . Three washhand basinfuls o f injectionwere thrown up , and then chlo rofo rm was given ,

the abdomen kneaded,and the m an was a lso inverted and shaken . “ Then he reco vered fromthe chlorofo rm he said he was relieved. Owing to the urgency o f the

previous symptom s , a consultation was held a c ouple of hours later ; itwas then manifest

,however, that he wa s much better ; n o further

vom iting o c curred (save slightly once) , and the man quickly and thoroughly rec o vered. T he nature o f the case did no t adm it of anydiagno s is being made 'but the case is imp ortant from the urgency o fthe symptoms, which were so rapidly relieved. The enema vis ibly distended the abdomen , and the o b struction c ould no t have been inlarge intestine . Med. Times and Dec . 14,Intes tina l o bs truction—Mr . Bryant writes on this subjec t Med.

Times and March 16, 30 ,April He deta ils a number

o f very interesting ca ses . Mr . Bryant relates cases in which he hasperformed lumbar c o lotomg, and remarks on the kind of cases adapted


Intestina l obstruction fo rmation of artificia l anus in sma l l intestine

Mr. M cCarthy rec ords a case o f o bstruction o f the bowels causedc ancerous disease, in which he m ade an inc is ion in the abdo min al w

be ii

r

d o f the stomach and had invo lved the Splen ic flexure o f the c o lon .

There was no t the slightest evidence o f periton itis . Mr . McCarthyremarks on the absence of p eritonitis . It is stated by autho rities to b ealm o st inevitable after such an Operation . Ano ther po in t o f interes twas the fact o f there being very fluid, but o therwise no rmal, faecalmatter in the p o rtion o f the bowel between the artific ial anus and theo b struction . It is als o no tewo rthy that the patient recovered. Med.

Chir. lv,Gastro tomy fo r intestina l o bstruction—Dr. Buchanan o perated on a

yo ung wom an who had symptom s o f acute intestinal Obstruction , suc

c essf ully . T he p atient was 2 9 years of age, in go od health . The

symptom s began with severe pain in the abdomen fo llo wed by vomiting.

On the third day, sterc oraceous vom iting o ccurred. On' the fo urth day,

Dr. Buchanan saw the patient . T he vo ice was husky ; her c ounte

nance was anxious and pale the extrem ities were c o ld her pulse wasweak ; and she was restles s and '

uneasy in whatever p o sitio n she lay.

The abdom en wa s distendedwith flatus . The m o st c areful exam inationfailed to detec t any p o int which c ould be referred to a s the seat o f the

o bstruction . An inc isio n was made from the umbilicus downwardsfo r abo ut four inches . As s o o n a s the peritoneum was Opened a quantity o f turbid serum flowed o ut and was c o llec ted

,altogether abo ut a

pint . It had very much the appearance o f whey,with flo c culi

,like

pieces o f curd, flo ating in it . It was very acrid, smarting the skin whenit came in c ontact with the hands . The intestines were glued togetherand one c o il was sharply bent o n itself. T he right hand was introduced into the abdom inal cavity and a tho ro ugh explo ration made.

The intestine was rem o ved from the pelvis with slight jerks to liberateany portion p o ssibly strangulated. An as s istant kept the bowels frompro truding from the abdom inal cavity. The pelvis was Sponged out.

The wo und was securedwith deep and superfic ial sutures . T he patientdid well afterwards . She had an attack of swelling o f the left lower ex~

tremity resembling ph legmasia do lens . Dr. Buchanan alludes to ca seso f sp ontaneous reco very in intestinal o bstruc tio n

, but remarks thatthere are few,

if any, in which sterc o raceous vomiting has go ne on un

interruptedly formore than forty-eight hours which have no t terminatedfatally . The cause Of the sterco raceous vomiting he suppo ses to havebeen the twist of the intestine held down by adhesion s or else the acridperitoneal fluid. Mr. Hanco ck, in 1848, perfo rm ed a somewhat similaroperation and let o ut a quanity of greenish, flo cc ulent serumdec ided relief o f the symptom s and ultimate cure o f the patient . Ina paper which Mr. Hanc o ck read befo re the Medica l So c iety, he advocated opening the peritoneum in o ther cases o f peritonitis in “

caseswhere the efl

'

used fluid destroys rather by its character than its quane

GASTROTOMY FOR INTE STINAL DE STRUCTION.

tity . where the sinking and typho id symptom s depend on the presence o f the o ffen s ive fluid in the peritoneum .

”Dr. Buchanan, a fter

the experience of his own case , was inc lined to make the same sugges

tion befo re he became aware that such hadalready been done . Lancet,

’

June 10,187 1 ,

Mr. Hulke publishes a c linica l lecture on the fo llowing case z—Aman ,

act. 3 2 , in go od hea lth , after a hearty meal Of fish,was seized with

pa in in the belly—he tho ught it co lic—shortly fo llowed by vom iting .

The pain left him ,but the sickness c ontinued. On the tenth day Mr.

Hulke found his belly un iforml y swo llen and hard,so hard that no rea

sonable pressure dimp led it . He Often vom ited a pea-soup - like fluid

having a faecal sm ell,which gushed Cop iously from his m o uth with but

little heaving . The only pain and tenderness in the belly,and this was

very s light, he referred to a Sp o t rather abo ve and to the right of thenavel . His pulse was small

,quick and weak . By a pro cess of

exc lusion well described by Mr. Hulke,it becam e likely that the

Obstac le was either a twist,or the entanglem ent o f a piece o f sm all

intestine in a ho le in the m esentery or omentum, o r an adventitious ,

constricting band. A negative reply to repeated question s whether hehad any previo us abdom inal ailm ent weighed rather aga inst the supp ositiou of a band, and favo ured vo lvulus o r entanglement with strangu

lation ,because an adventitious band necess itated a previous p eritonitis ,

and o f this there was n o histo ry ; but then a very lim ited and sub -acuteperitonitis m ight have passed unno ticed it m ight have been ,

s o to say,latent, just as the po st-m ortem theatre teaches us daily with regard topleurisy and p erio rchitis, revealing adhes ion s o f the c o stal and pulm o

nary p leurae, and o f the testis and parietal tunica vaginalis in the bo dieso f persons in whom during life thesem aladies had not been suspected.

”

The abdomen was op ened by a cut in the m edian line m idway betweenthe navel and pubes , through which the hand was passed and an emptyp iece o f small intestine sought for, by tracing which Mr. Hulke hopedto b e led to the Obstruc tion . The distension Of the small intestinescaused great difliculty. Many feet o f intes tine had to be drawn o ut

and returned again . The o bstacle rema ined undisc o vered. T he bowel

was tapp edwith a veryfine trocar . Much stinking gas hissed o ut, but

o nly a few inches of bo wel c o llapsed, and on pulling o ut the canulathin pea-soup -like faeces o o zed through the prick . An attempt to tieup the Open ing resulted in its becom ing larger. Thep zmetnrecl gutwas

s lit up and stitched securely to the skin : a large panful o f fluid fascesimm ediately ran out. The relief was prompt and remarkable the

vom iting ceased and the belly became soft ; he had no pain ,and his

temperature was no t raised ; this, however, was not c onclusive as to the

absence o f peritonitis . Fifty-three hours after the o peration the

patient died exhausted. At the po st-m ortem the intestine and peritoneum were found inflamed the sigmo id flexure of the c o lon had avery long and lax meso -co lon, which al lowed it to stretch in an angularlo op acro ss the pelvis from left to right . At the apex Of the lo op, along epiplo o ic appendage, issuing from the free bo rder of the gut, gaveattachm ent to one end o f a thin, glisten ing, tendinous band, the o therend ofwhich cro ssed and tightly tied downthe ileumabout three inches


distant from the caecum,and lo st itself on the peritoneal lining o f the

pelvis near the right sc iatic no tch . T he band m ight have been easilyreached and safely out had its seat been disc o vered during the ex

p loration . The les so n s drawn from the c ase are, that no twith

standing its fatal issue, the as certained practicability o f cutting the c on

stricting band is an enco uragement to o perate again under sim ilarc ircumstances . Next, the acute and general enteritis a nd the ulcerationat the c onstriction ,

already present when the Operation was done, showh ow m uch danger grows with delay. Again, we learn that the plan o f

pun cturing inflated intestines for the purpo se o f letting Off gas is safeonly when the gut do es no t also c ontain fluid faeces ; and when ,

unspo iled by inflamm ation,its muscular c o ats can shrink and c lo se the

puncture, assisted by a slight sliding o f the muc o sa but where the gutis damaged by inflammation , and c ontains also fluid faeces as well asgas , the hindrance to the search caused by tight packing o f the

inflated intestine, will b e m ore safely dea lt with by a freer section o f

the walls than by punc ture. We are taught , also , that fixed tendernessand pain are very uncertain guides to the seat o f an o bstruction

,fo r

here that situation p o inted to the upper end o f the small intestine,while the Ob struction was c lo se to the c aecum . Lastly, in traumaticperiton itis we may expec t a low temperature, and are no t to be thrownOff our guard by the absence Of a high o ne.

”

Mr. Thom as Annandale narrates a case in which he perfo rmedgastro tomy on the fo urth day Of obstruction o f the bowels

, and divideda band o f lymph . T h e patient died about eighteen hours after theOperation . He was a man aged 5 5 , who was taken sudden ly withsevere pain in the abdomen . c al vom iting rapidly set in , showingthat the o bstruction was c omplete. Mr. Annandale sum s up (I ) whenthe symptom s o f sudden and c omplete intestinal o b struc tion are

present, and the o rdinary meaus Of treatment have failed to give relief,the o peration o f gastro tomy is justifiable and advisable . (2 ) That theOperation should no t

,if p o s sible, b e delayed beyond fo rty-eight o r

th irty-six hours after the first symptom s have appeared. (3 ) That theabdomen should b e Opened in the m iddle line ; and, that during theoperation and after it every precaution should be taken to lessen therisks o f periton itis . (4) That when the abdom inal cavity is Openedthe best guide to the seat o f Obstruction i s the c ontracted o r dilatedc ondition o f a po rtion Of the intestine. (5) That if the intestine b egangreno us, o r the Ob structio n no t rem o vable

,its c anal should be

o pened as near the o bstruc tion as po ssible, and an artific ial anusestablished. (

‘E din . Med. J Feb .

In the ‘Brit . Med, March 2 3 , 1872 , is an abstract of a

case rec orded in LO Sperim entale’ fo r March,1872 . T he patient was

a man aged 2 5 , who had double inguinal hernia . Symptoms o f internalstrangulation came on while bo th hernias were reduc ible . On examining one, by o peration ,

and passing the finger into the abdom inal cavitya knuckle o f intestine was fo und tightly strangulated by a hard fibrousb and

k

This was divided. T he p atient left the hosp ita l, cured, in a

mont

Op ening the stomach for cancmz—Three cases in which the stomach


at least an inch and an quarter in length . The pipe should also be provided with an india-rubber flange to prevent its pass ing to o far in . T he

pipe terminates ins ide the bag in a s o rt o f ro se which is surm o untedby a delicate, flexible, hard-rubber probe four inches long, and to whichthe capo te, o r bag, is attached superiorly . The probe is screwed intothe pipe at its bulbous end and may be replaced by o thers o f differentlengths and flexibility . He alludes to o pinions o f autho rs on the

rectum in relation to syphilitic stricture and c onsiders that suflicientattention has no t been called to this fo rm o f stricture . The seat o fthe stricture is at the junction o f the dilated part w ith the sphincter,about one inch and a half from the anus . T he patients

,with very rare

exception s, are women . Fissures and fistulas in ano and in perineo , o rfi stulous tracts o pening into the labia , sometimes complicate stric tureOf the rectum ,

and c ondylomata about the anus are frequent . T he

stricture may be partly fibrous , tight and unyielding, the fibro us c onstriction being from half an inch to two thirds o f an inch in extent, o rthe stricture, while fo rm ing, m ay produce the sensation to the fingero f irregular elevations o r o f crescentic fo lds which readily break downfrom pressure o f the finger. The intestine sometimes four o r five

inches abo ve the stricture is ulcerated and the extensively ulceratedsurface is term inated superio rly by a festo oned b order . There is c onsiderable purulent secretio n and the contraction Of the sphinc terfavo urs its accumulation in the ampulla . It lasts for m onths o r years

,

before the formation of a stricture . T he mucous membrane may be

so s oftened that a bougie easily penetrates it and m ay enter theperitoneal cavity. If the ulceration is low down pain on defaecationis complained of, if higher up there may be no pain . T he patientsare generally between 1 7 and 40 years o f age . Owing to the anatom icalrelations o f the anO-

genital regio n o f the female,the chancrous matter

o f the syphilitic sores, nearly always present on the vulva , infects thisregio n , o c casioning rhagades o r fissures o f the anus . T he ul cerationextends to the ampulla o f the rectum ,

where it remains long after thehealing o f the external so res and o n c icatrising c auses a tight , fibro usstricture . The stricture is lower down than in cancero us disease . An

antisyphilitic treatm ent is wo rse than useless . It do es harm b deb ilitating. When the stric ture is fibrous , it Sho uld be very g‘eelydivided with the knife o r Sc issors and kept roperly dilated. Chlo rideo f zinc o r carb o lic acid sufliciently diluted

J

should be applied to theulcei

iated part abo ve. Am . Journ . Med.

,Sciences

,

’

Jan. 187 1 ,1 I5 .

Remova l of a p ortion of bone from the recta l fossa . Dr. Thompsonrelates the case o f a man

,aged 70 , who , twenty years previo usly, had

begun to suffer from pains in the back and pelvis . After five yearshe c onsul ted a surgeon , who could not find anything the matter .

When he c ame under Dr. Thompson’ s care he c omplained o f “ piles . ”On exam ination an almo st raw surface was found extending two inchesround the anus and a zone o f erysipelatous blush four inches inbreadth . On the left side

,abo ut an inch from the anus

,there was a

small Opening, through which appeared a small bla ck po int . This wasseized and drawn o ut by slightly enlarging the o rifice and proved to

OVARIO‘TOMY .

be a piece of bone three quarters o f an inch Square . NO p iles werefo und. A pro be passed thro ugh the Open ing entered the rec tum a

short distance abo ve the Sphinc ter, and a c onsiderable cavity remainedwhere the b one had rested . The fo llowing day two o ther small p ieceso f bone were rem o ved. The fistula was subsequently slit up . The

patient dec lared that he felt m ore c omfo rtable than he had done fo rtwenty years . He regained his former activity . T he pieces o f bo newere exam ined and were po ssibly portions of the scapula o f a rabbit .The patient thought it had been “

in him all tho se years,

”if s o , it must

have lo dged in som e part o f the intestine, ulcerated its way o ut and

gradually reached the pelvic o pen ing . There was no history o f anyinjury to the Spine or sacrum . Lancet,’ Aug . 2 6

,187 1 ,

Ovario tomy.

—Mr. Alc o ck o perated on a child three gears o ld. The

tumo ur was universally adherent . The patient died at the end o f

fo rty-eight ho urs . Lancet,

’Dec . 16

,187 1 , 8

Dr. W . Barker has o perated on a child aged s ix years and eight

months . T he case was one o f derm o id cyst of the right o vary . The

patient rec o vered. Philadel . Med. Tim es,

’N ov. 1

,187 1 , and

‘Am .

Journ . Med. Jan . 1872 ,A case Of ovarian disease on which Dr. Newman Operated, using

antisep tic ligatures and dressing, is narrated in the Med. Times andFeb . 1 7 , 1872 , 184 . Haem o rrhage o ccurred into the peritoneal

c avity and the wound was Opened (under carb o lic spray) o n the tenthday . About three oun ces o f “ dark c o loured and s lightly o ffensiveblo od” was let out. The patient reco vered . Dr. N ewman regrettedhe had n o t used a c lamp instead o f the catgut ligature.

Mr. Spen cer Wells publishes further tables o f ho sp ital cases in theMed. Tim es and Gazette

,

’

Feb . 1 8 and March 2 5 , 187 1 , 187 and 337 .

A fourth series o f 100 ca ses o f o vario tomy are rec o rded by Mr . Wellsin the Med -Chir. l iv

,2 63 . Of the first 100 cases

, 34 died ; o fthe sec ond 100

,2 8 Of the third 100

,2 3 o f the fourth

,2 2 . Remarks

are added on the diagno s is o f uterine from o varian tum ours . Mr .

Spencer Wells has c ontributed a fifth series o f 100 c ases o f o vario tomy,

with remarks on the results o f 500 cases to the Med . Chir. N ov .

2 6,1872 (abstracts in ‘Med. J In the ‘Brit . Med.

M ay 18,1872 , is a short editorial , gro up ing together various s tatis tics

of o vario tomy .

A case o f unilo cular ovarian tumour, with pelvic and intestinaladhes ions , Operated on suc cessfully by Dr . W. L . Atlee, is given . In a

sec ond case o f multilo cular tumo ur, with extensive adhesions, deatho c curred. Am . Journ . Med. April, 1872 ,Dr. W . L . Atlee rec ords five cases of ovario tomg . Three patientsrec o vered and two died . In one o f the suc cessful cases there wereextensive adhesions, in the two o thers there were none . In o ne

case there was a pervious urachus . In each of the fatal cases therewere extens ive adhesio ns . All were multilo cular. Am . Journ . Med.

July,1872 , Dr. W

’

. L . Atlee reco rds further cases (Oct .

187 1 , In one in which reco very o ccurred a ligature had been tiedround a detached po rtion o f peritoneum . When this came away an

artificial anus was found to exist . This gradually clo sed. During its


existence the bowels acted regularly. In two o ther casefo llowed.

T en cases Of o varian disease Operated on at the Ho spital fo rare detailed in the Lan cet

,

’187 1 (March 2

, 9 , and In

c ases the pedic le was tied and dro pped in . A double Ipas sed through the c entre o f the pedic le and tied on each si

o ne o f the li

on ho lders , wrung o ut in warm water befo re the sutures were inserted.

When the wound was bro ught to gether a bro ad strip o f strapping wasplaced acro ss the abdomen tightly from hip to hip, and a large linseedm eal p oultice with a drachm o f laudanum was applied and changedevery four o r six hours and c ontinued fo r six o r seven days . Seven o f

the patients rec o vered, three died.

Dr. W . F . Atlee rec o rds a suc ces sful case o f o vario tomy,and also a

case in which he suc cessfu l ly removed an enlarged uterus which wa s

c ons idered to be an o varian tumour . Dr. W . L . Atlee’ s c lamp was u sedin each instance . Am . Jo urn . M ed . S c ienc es , ’ July, 187 1,Dr . Packard relates a s om ewhat s imilar case . T he tum our was n o t

remo ved. The patient died (Oc t. 187 1 , (See previous ‘Bien .

Retro sp .

’

also .)Mr. Keith reco rds a third series cg

“

50 cases . Of the last 100 casesthere have been 84 rec o veries . E ight o f the last 50 patients died : 2

from Obs tructed intestine,1 from acute septicaem ia, and 5 from perito

nitis . In 2 o f these the adhes ions were c onsiderable,in 1 m o derate,

while,in 5 , the tum o urs were non -adherent . In 6 o f the fatal cases ,

the c lamp was used ; in 1, catgut ligatures to one o vary and c lamp to

the o ther ; in ano ther the long ligature Of Dr. Clay . In nearly o ne

third o f the c autery c ases,bleeding to o k place from large vessels and

ligatures were nec es sary . Lancet, ’ N o v. 16,

Trea tment of supp urating ovarian cys ts and p elvic adhes io ns in

ovario tomy .

-Mr . Ho lmes remarks on a case o f Ovarian disease in whichafter a prelim inary tapping, apparently revealing a single cyst witho utc omplication s , suppuration o f the cyst ensued . The patient c om

plained o f c on stant pain in the right iliac fo ssa, and became veryemac iated. She was sent to a convalescen t home at Wimbledon .

When she had impro ved as much as She was likely to do,Mr. Ho lmes

o perated. A large quantity o f pus was let o ut . Many adhesio nswere found, but al l were separated till the brim o f the pelvis was reached;here there were very firm adhesions . The remains o f the cyst werepulled out as far a s p o ssible, the intestines returned into the bellyand the lower po rtion o f the cyst c lamped. The wound was unitednext day there was a little o o zing of blo od from the wall s o f the cyst,which were nearly half an inch thick . A strong ligature was passedthrough the m ass abo ve the c lamp, and the expo sed edges o f th e cystwere seared with the actd al cautery . The c lamp was remo ved on the

third day . T he sloughing stump gradually receded and tympanitesbecame developed. She rec o vered gradually, but c ompletely .

Mr. Ho lmes remarks,

“ The internal inflammation which leads tosuppuration will, I should suppo se, usually, if no t always, be acc om

REPORT ON stas sfit’

.

cyst as far as po ssible o ut o f the abdomen and apply a c lamp toneck ; o r to apply a c lamp tempo rarily, cut away the cyst, sear

cut edges with the cautery and return the ma s s into the abdomeninstead o f the cautery to us

thin enough to b e embraced in the c lamp . The internalcyst is thus brought into c ontac t and m ay adhere and o bliterate thec avity , as seem s to have o c curred in o ur patient . If this do es no ttake p lace, at any rate the resulting inflammation during the heal ing o f

the wound will probably exc lude the mas s from the peritoneal cavity,just as effec tually as if the edges were stitched to the wound ; whilstthe plan is free from the dangers incurred by leaving the remains o f a

suppurating cyst free in the

pelvis , and tho se resulting from the

irritation o f ligatures in the pe vic c avity . Mr . Wells relates a casein which the ligatures set up m ischief. The c ase befo re us was an

example o f c omplete, and,I must allow, unexpected suc cess . I ex

pected that when the clamp and p in s had been remo ved a suppuratingsinus wo uld be left pro ceeding from the interio r o f the cyst, whichwould o nly gradually dry up, if at all . Such a result would no t, how

ever, b e inc onsistent with go od health and activity .

” At the end o f a

year the patient remained quite well . The c icatrix was quite so undand free from irritation , with no perceptible swelling beneath it .Med. Chir. lv,P eritonea l inflamma to ry cgst resembling an ovarian tumowr.

—Dr.

W . L . Atlee rec o rds the case o f a married wom an, who at her las t c on

finement, five m onths previo usly,had been disco vered to suffer from a

tum our o n the right side o f the uterus . Some days after childbirthshe was seized with rigo rs fo llowed by fever and suppo sed peritonitis ,and a rapid developm ent o f the tumour, with great c onstitutional disturb an ce and emac iation . When Dr. Atlee saw the patient she waslarger than a woman at full term . N o twithstanding the case was veryunfavo rable fo r o peration ,

in c on sequence o f the acutenes s o f the o riginalattack , the rap idity o f the development, the pelvic c omplication, the displacem ent o f the uterus , and the general c ondition o fthe patient, it wasdeterm ined to make an explorato ry o peration, as it was believed at the

time that the tumour was o varian . An inc is io n was made , and a cystfound, which was no t o varian ,

b ut came from the pelvis . The cyst waslaid open,

and fifteen p ints o f greenish pus and numero us large, stringyc lo ts o f fibrinous matter let o ut. The patient died o n the third day .

After the operation I suppo sed that the o riginal tum our was a pedunculated, uterine fibro id tum our, that inflammation had supervened, andthat an abs ces s had fo rmed within it

,which had caused 1t to partake

o f the characteristic s igns o f a unilo cular o varian cyst . Subsequentexperience, h owever, sat1sfied m e that this last Op inion was erroneous,and that the tum our o riginated in the pelvis through inflammationlo calised in the peritoneum, agglutinating the serous surfaces, and

fo rming po ckets wherein to receive the resulting fluids o f this inflamma

OVARIOTOMY—CLAMPS, ETC. 305

tion, fo rming what I denom inate, in my bo o k on the diagno sis o f

o varian tum ours, a'

p eritonea l infl ammatory cgst.” Am . Jo urn . M ed.

July,1872 ,

Large o varian cgst tapp ing inflammation great prostration

ovario tomg ; recoverg .—Mr. John Clay records the case o f a patient

who was in extreme pro stration resulting from inflammation o f an

bvarian cyst after tapping, when he performed o vario tomy with suc cess .Lancet

,

’Sept . 7 ,

Cases -

of o vario tomy, under the care of Dr. W . L . Atlee, are given .

Am . Jo urn . Med. Jan . 1872 , In one c ase the cyst wasful lofp us , and was everywhere adherent. Neither c lamp no r ligature wasused, the vessels o f the pedicle having been destroyed by inflammation .

A second c ase was one o f cyst o f the bro ad ligament . A thirdwas multilo cular with extensive omental adhesions . All the patients rec o vered.

A case i s als o reco rded which was under the care o f Dr . John L . Atlee .

The cyst was multilo cular,there were slight adhesions, and the patient

rec overed. (p .

Wound of intes tine during o va/rio tomy, with recovery .—Mr. C . Heath

records a case in which he operated fo r o varian disease, and, in enlargingthe abdom inal wound with sc issors

,cut a piece of intestine which became

entangled between the blades . He stitched the intestine to the ah

dominal wound,and s o fo rmed an artific ial anus . After some tim e he

app lied the actua l cautery to induce the o pening to c ontract. It neverquite c lo sed ; but the patient became fat, and a pad and belt suflicedto prevent all extrusion o f faecal matter. Mr. Heath remarks that hebelieves no sim ilar case is on record, and it will serve as a warn ing tosurgeons to b e on their guard against adherent intestine . If such anac c ident should o ccur he thinks the p lan he adopted the best whichc ould b e carried out. C lin . So c . v

, 3N ew c lamp s , de—Dr . W . L . Atlee describes and figures a new

c lamp,c onstructed s o as to ensure a parallel grip , and adm itting adap

tation to a narrow o r wide pedicle . Amer. Journ . Med. Sc iences,

’

April, 187 1 , At p . 398 o f the same j o urnal he narrates sevencases of o vario tomy. Two o f the patients recovered, five died. Furthercases are given July, 187 1 , 1 2 8. They are three in number. The

patients rec o vered,but in one, the tum o ur was not remo ved.

Dr. Dawson has invented a new clamp . It is oval . One limb liftsaway from t he o ther, the pedicle is inc luded, the limb fixed, and thenan inner V-shaped p iece is screwed down on the pedic le . This may becut through with the c lamp if desired. Am . Journ . o f Aug.

187 1 , quo ted ‘Am . Journ . Med. Sc iences , ’ O ct. 187 1 ,D ivision of p edic le in o variotomy .

—Dr .Mac leod, o f G lasgow, suggeststwisting ofl

’

the pedic le in o vario tomy,and returning the stump who lly

within the abdomen . He uses strong forceps with stirrup -shapedblades

,the straight ends answering to the straight cro ss-bar o f the

stirrup fit into one ano ther when c lo sed. T he pedic le is grasped withthese

,then the tum our is cut o ff at a like distance from the fo rceps ,

and the cut extrem ity seized by ano ther pair of forcep s, and s lowlytwisted o ff. In one case in which he tried this plan it succeeded perfectly . There was no haemorrhage. He returned the stump within

20


the abdomen and clo sed the wound. The patient made a ra

recovery . Figures o f the fo rceps are given . Lancet,’ Jan .

187 1 ,Dr. Beebe reco rds cases in which he severed the pedic le

and twisted each vessel as it bled, afterwards returning thethe abdomen , and c lo sing the wound carefully. Five c ases

Am . Journ . Med.

Sc iences, ’ April, 187 1 , See also Dr. No tt’ s rectilinear écras eur .

O’wsarean s ection—Dr. Phil ip Fo ster records a case in which heperformed Caesarean section successfully, as far as the m o ther wasconcerned. Lancet,’ June 1 , 1872 ,Dr. Harris has c o ll ected c ases o f Caesarean section performed in the

United States, and tabulated them . They are seventeen in number.

Twelve o f the women recovered, and fourteen o f the children weresaved. The o perations were perfo rmed during or at the c lo se o f the

first day o f lab our, Showing the value o f timely surgical interferen ce .

In all o f the cases but one the child was remo ved alive .

” Am .

‘

Journ . Med. July,1872 , 2 90 , from

‘Am . Journ .

Vaccino -syp hilis .—A case was brought before the Clinical So c iety by

Mr. Thomas Sm ith iv, 5 Subsequently two series o f c aseswere brought before the Medico -Chirurgical S o c iety by Mr. Hutchins on, and were reported on by a Comm ittee. F irs t s eries , sgno sis

Twelve persons,m o stly young adults, vacc inated from a healthy-fo okingchild. Satisfacto ry progress o f the vaccination in all . Indurated

Reinfection with c onstitutiona l syphilis—H . Ko bner, in the Berliner

Klin . NO . 46, 1872 , remarks that Ricord had assertedthat syphilis can be contracted once o nly during life ; a new infec tioncanno t take lace. This do ctrine has been generally accepted, especially by the dhalists ; but KObner calls it in question . He relates anumber of cases o f repeated infection which he has observed, amongwhich is the fo llowing —A man

,set. 40 , had, in May, 1866, a sore on

the penis, ro seo la, and sore throat, for which he was treated with mer

cury ; in No vember,1868

, he had syphil itic sarco cele on the right side,and a no de on the manubrium stern i . He was now treated by Kohnerwith iodide of p o tassium and mercurial o intment to the scro t um ,

andat the end o f the year was able to resume his wo rk . During the next twoyears he suffered o c cas ionally from pains in the limbs and sternum ,

for

the relief of which he to ok iodide o f po tass ium, but did not seek medical

308 REPORT ON suRGER’r

’

.

appearances at the p om t o f transition from the diaphys

physial cartilage . There is first a layer o f hyaline cartilagan indented layer o f mortar-like subs tance ab out fo ur c

thickness,and

,finally there is a so ft,

irregular, defined at the upperdiaphysis . These three stagesthe same individual . Wegner

o steo chondritis arising from syphilitic c ondition o f the blo od. The

long bones , and the epiphyses o f tho se which c ontribute m o st to growth ,were spec ially affected. Along with these changes in the bones , fattydegeneration o f the cells and vessels o f the m edulla is o ften found insyphilitic children

,the marrow a ssum ing a reddish-yellow o r light

yellow instead of a red c o lour. (‘Wiener Med. No .

8,18

Dr

?Taylo r’ s essay (reprinted from Am . Journ . Syph . and

Jan . 187 1) on dac tylitis syphilitica, that is on late syphilitic affectionso f the fingers and to es, is a useful c ontribution to o ur knowledge o f thisrare form o f disease

,which has been generally o verlo oked by writers on

syphilis . He has added to several published cases two that came

under his own o b servation and has constructed a sho rt, but valuable,essay . The disease c ons ists o f gummy infiltration o f the subcutaneousc onnective tissue, the ligaments, perio steum , and bones o f the phalanges . By this m orbid pro cess , irregular enlargements are pro ducedin bo th fingers and to es , sometim es fo rming ro unded swell ings o f theb one and perio steum near the first phalangeal articulation

,which

strongly resemble enchondromatous tumours . In o ther instances theenlargement spreads chiefly in the sheaths o f the tendon s and c onnec

tive tis sue, fo rm ing a dull, red, brawny thickening o f the who le digit .These affection s yield readily to Spec ific remedies . The essay co ntainsal l the cases hitherto rec orded o f this peculiar affection and fo rms animportant c ontribution to syphilitic patho logy. Med.

-Chir . Review, ’July

,187 1 ,

Subcutaneous inj ections of mercury in syp hilis—Dr. Sigmund, o f

Vienna,writes on this subject in the Wien . Med. Wo chenschr.

’for

Sept . 9 , He first exam ines the disadvantages which , ac c ord

ing to the Opponents o f the pro ceeding, attend it ; viz . the fo rmationo f subcutaneous depo sits ; inflammatio n, abscess , and their results ;the pain attending the pro cess o f injection ; the difficulties o f the proc ess ; the disturbance which it produces in the c irculato ry and respiratory system s ; stomatitis and salivation ; and

,finally

,the small

amount o f success attending subcutaneous injections as compared witho ther plans o f treatment .T he formation o f subcutaneous infiltration at the seat o f injection

no doubt o ccurs ; but, under rest and care o f the affected parts, c omplete absorp tion o f the depo sited material gradually takes place . Theo c currence o f inflammation and abscess is

,no doubt

,very troublesome

and interferes with the cure but it depends entirely on the manner inwhich the injection is made, on the strength o f the so lution used

,and

on the management o f the patient after the o peration . Sigmund has

MERCURIAL INJECTIONS IN SYPHILIS . 309

eous injections in m ore than 2 00 cases o f syphilis inprivate practice, and has twice only met with abs ces s as

a result. The patients were o f bo th sexes, o f various ages and c on

stitutions , and affected with syphilis in very various stages . Somepatients had as many as thirty injections ; usually o ne daily, sometimeso ne every second or third day . The parts cho sen for injection weregenerally the trunk , sometimes the arm s, care being taken to avo idparts that were liable to be lain upon ,

o r to b e subjected to m o vemento r pressure . T he pro cess o f injection was perfo rmed with great care,and the patients were required to pro tect the parts well and keepthem at rest . The so lution used in alm o st all the cases was that recommended by Lewin—four grains of bichloride o f mercury in an

ounce o f distilled water. If patients are

'

allowed to go heedles sly totheir o rdinary o c cupation s immediately, o r two o r three hours after theinjec tio n

,the o c currence o f inflamm ation and ab scess must be ascribed

to this and no t to the o peration .

T he pain attending injection in Sigmund’s cases varied much, butwas usually very s light and o f short duration ; in m o st c ases

,it was at

once allayed by c o ld application s . In a few cases, the pain was severeand lasted fo r some time, no matter at what part o r with h ow muchgentlenes s the injection was made . Patients in whom this o c curs areno t fit subjects fo r subcutaneous injection ; in them even the additionof hydro chlorate o fm o rphia to the so lution do es no t prevent the o ccur

rence o f the pain .

The details and difficulties of the o peration are scarcely worth c on

sideration . G o od instruments are easily pro cured, and can be easilykep t in go od order. The operation is no t a difficult one, and even if ito ccupy a go o d deal o f the surgeon ’s time

,that time is not lo st if the

result be successful .Stomatitis and ptyalism o c cur frequently if the patients do not c leansetheirm ouths c arefully and o ften . Dr. Sigmund has very seldom met witheven slight affections o f the gum s in his patients , but he uses prophylactic measures . He has never met with disturbance o f the c irculationand resp iration, o r any o ther general disorders o f any importanceattributable to the mercury . T he m ethodically c ontinued use o f all

mercurial preparations is attended w ith a m o derate increase o f the

heart’s action and o f the temperature gastric disturbances o fteno c cur, but are to b e attributed generally rather to the dietetic c ondition o f the patient than to the treatment . The secretions o f the skinand kidneys are but rarely disturbed in cases which must be regardedas exceptional . The chemic o -vital pro cesses in the blo od and secretionswhich lead to the impro vement o r cure o f the various fo rm s of syphilis ,go on with out any remarkable func tional disturbance and if any sucho ccur

,it i s pro bably due to o ther causes than the injection .

There has been a great difference o f Opin ion as to the abso lute and

relative value o f the subcutaneous m etho d in the treatment o f syphilis .It wo uld b e imp o ss ible to arrive at a c o nc lus ion from the observationso f a few p atients during a lim ited tim e

,fo r the disease recurs at inter

vals in a variety o f fo rms, continues long even in favo rable cases, and at

intervals manifests itself so feebly that it appears to have disappeared.


There is also the difliculty, even when a patient is kept under observation for a number o f years, o f knowing whether he c onfines him self tothe prescriptions o f his m edical adviser, or uses sometimes tho se o f o therpersons . The question as to the

o

value o f sub cutaneous Injection In

syphilis is no t yet ripe for decis1on ; a pro longed ser1es o f c linicalo bservations is required.

One o f the alleged advantages o f subcutaneous injection in syphilisis the po ssibility o f allowing the patient to m o ve about and fo llow hiso rdinary o ccupation . This advantage, however, is lImIted ; for the

wound made in the operation demands rest and care for a t1me at leas t,

and it is often necessary simultaneously to apply lo cal treatment to thegen ital organ s, m outh and thro at. In the treatment p f syphilis, Sigmund insists m o st strongly o n the impo rtance o f pure a mand exerc ise ;but when injec tion is used much care i s required.

An essential advantage of subcutaneous injection, and one whichcanno t be o verrated, is its precision . The surgeon knows when

,how

much , and where he introduces the medic ine into the system ,and can

determ ine with the greatest accuracy the place, the time, and the

repetition of the do se. Again, there i s no immediate disturbance o f

the digestive o rgans . Perfection in the details o f the o peration, and

attention to the hygienic and dietetic conditions o f the patient are them o st important po ints to b e observed in a long and varied inquiry madewith the view o f arriving at a c onclusion as to the value o f the pro ces s .In Dr. Sigmund

’s Opinion , no one as yet po ssesses the fac ts on whichan abso lute c onclusion may be fo unded. Subcutaneous injection mustb e regarded as a valuable addition to our resources

,inasmuch as—un

fortunately no t rarely—cases are met with which resist all the o rdinarymethods o f treatment . As far as Dr. Sigmund has o bserved, its go o deffects are m o st readily o btained, and are apparently permanent in thesimple papular, pustular, and squamous syphilides

,in simple fauc ial and

laryngeal catarrh , in diffuse inflammation o f the musc les and tendons,o f the perio steum and perichondrium and o f the j o ints , and in neuralgicaffec tions . It may also be used empirically where o ther methods havefailed, o r where, fo r spec ial reasons , they canno t be carried out. T o

cases o f the kind here referred to , Dr. Sigmund would limit the use o fsubcutaneous injection in private practice . Clinical observations

,on

the o ther hand, must embrace a wider range. As far as Dr. S igmundhas Observed, he finds that he c anno t support one o f the as sertions o fthe advo cates o f subcutaneous injection ,

viz . that it prevents secondarysymptom s when employed in the initial s tage, o r that o f induration .

In al l the cases which he has thus treated, the c o nsecutive,cutaneous

and muc ous syphilides have appeared, just as if the disease had beentreated lo cally o r no t at all .Subcutaneous injection po ssesses an advantage in common with

friction and fumigation, namely, that internal remedies , such as quinine,iron, preparation s o f iodine, c o d-liver o il

,&c . , can be given at the same

time. Dr. Sigmund attaches much imp o rtance to this fact, since suchc ombination o f treatment is o ften o f high value.

In concluding, Dr. Sigmund insis ts on the necessity,in o rder to

arrive at an estimate o f the value o f subcutaneous mercurial injection


time were made on each c ase fo r three o r four hours onl y ; subsequently,however, he has no ted the temperature c ontinuously fo r periods varyingfrom eight to twelve hours . He finds that the cases (twenty -one in

number) can b e arranged in three princ ipal c lasses . 1 . Tho se (ten) inwhich the temperature remained below the n o rmal ( 100° 2

,

tho se (six) in which the temperature ro se slowly abo ve the no rmal ;and

, 3 , tho se (five) in which it ro se rapidly, s ometimes reaching, in a

few ho urs , even 1 04° Fahr. In m o st o f the cases the rise c ommences

from half an hour to two hours after the o peration, being, in rare in

stances , preceded by a fall, which probably o ften o ccurs befo re theobservation c ommences, and escapes no tice ; while in some instancesthe rise o f temperature is a ttended by intercurrent fall s . These differences canno t b e acc ounted fo r by the nature o f the injury and its immediate efi'

ects on the tissues ; the state o f the temperature depends ono ther c ircumstances , which may b e c alled acc idental . Great lo ss o fblo od lowers the temperature . This has been proved experimentallyby Weber

,Frese, Kettler, and Bergmann . Chloro fo rm also has the

same effect, as was po inted o ut in 1848 by Duméril and Demarqua

and the Observation has been confirmed by Scheiness on ,o f Do rpat,

experiments described in an unpublished thesis, which Billro th has hadan oppo rtunity o f reading. Pain

, perhaps, also lowers the temperature ,but in some cases it was attended with a rise. Rapid sec tion o f the

large nerves , and their m ore o r les s abrupt laceration ,as in the remo val

o f tumours,may pro duce a depressing influence on the temperature, a s .

i s o bserved in sho ck . The expo sure o f the patient unclo thed to theair fo r to o long a time, espec ially in w inter, in the Operating theatre, isliable to pro duce a fall o f temperature . T o this, SpencerWells attachesm uch impo rtance in o vario tomy ; and. Billro th remarks that, since hisattention was directed by Mr. Wells to the necessity of no t allowingthe temperature o f the o perating ro om to fa ll below 77

° Fahr.,he has

never seen such marked co llapse during and after o vario tomy as hefo rmerly met with . In two cases Observed by Billro th a temporary fal lin the temperature, which had been high or ris ing, was produced byhaemo rrhage : and in ano ther instance o f fever

,daily variations were oh

served, which corresponded with tho se no rm ally o ccurring in the heal thysubject, there being a fall between 5 and 7 p .m . 3 . In the thirdchapter, Billro th describes a series o f researches on the o rdinary temperature o f the rectum in dogs . He fo und it to manifest frequent o scillatio ns

, which were pro ved, by the use o f spec ially pro tected thermom eters , no t to be dependent on muscular action . 4 . The influence o fmuscular ac tion on the temperature is discus sed in the fo urth chap ter.

Very slight changes , if any , are pro duced in the temperature o f hea lthym en by muscular exerc ise ; in animals

,however

,the effec t is greater.

The artificial pro duction o f tetanus in a limb gives . rise,as shown by

TRAUMATIC PEVER. 313

to an increase o f temperature in the part . 5 . In the fifthBillro th exam ines the influence o f various injuries on the tem

perature o f the rectum in dogs . He finds that even severe lesions,such

as the ligature o f arteries , o r long inc is ions through the skin,have no

c onstant effect on the temperature in the rectum within three hours,

even when the experiments are perfo rmed on animals that have beensuffering from illness . 6 . The application to the extrem ities o f the

nerves o f mechanical and chem ical irritants, such as injection o f air orwater into the subcutaneous tissue, irritation with cro ton o il o r withammonia, &c .

,had no constant effect in elevating the temperature in

dogs, even when continued for two o r three hours . The influenceof irritation o f the vaso -m o tor nerves on the temperature has beenstudied by Billro th by means of (a) the intro duction into the vesselso f canul ae o r pieces o f tangle, which produced no

,resul t ; (b) the

introduction o f purely mechan ical embo la,such as starch o r powdered

charco al suspended in water. The injection o f these into the systemicarteries was fo llowed by a fall in temperature rather than a rise ; whenthey were introduced into the jugular vein ,

and thus reached the pulmonic c irculation ,

fever was not a c onstant result, but the temperaturepresented a remarkable series of to lerably regular falls and rises

,such

as had already been no ticed by Albert and Stricker. 8. In the eighthchapter Billro th Speaks o f septicaemic fever in a dog. A filtered infusion Of putrid muscular tissue, swarmingwith vibriones , when injectedin large quantities into the arteries , veins, o r subcutaneous areo lartissue

,rapidly pro duced death ; when injected in smaller quantities (five

centigrammes o r less) it produced fever o f a rem ittent type,lasting

several hours . 9 . Regarding pyaemic fever in dogs, experiments aredescribed in the n inth chapter, the result o f which was that the injection o f pure pus , or of pus diluted with water, was sometimes fo llowedbyfever, sometimes no t. 10 . A similar inconstancy of results attendedthe injection, in a similar manner, o f water, o f serum ,

and o f the fluidr

o f hydro c ele . 1 1 . In c ommenc ing, in the eleventh chapter, a criticalexam ination o f the resul ts described in the preceding part o f his es say,Billro th says that their great variety is one o f the princ ipal Ob stac lesto their use in forming a theory o f fever. Two phenomena only arec onstant—the rise o f the temperature after muscular action ,

and after

the injection o f putrid matters . Referring to the effect o f muscularaction , he says that the artific ial tetanization o f l imbs and the effec t o fvo luntary muscular m o vements can b e ac cepted as starting-po ints in theinquiry only so far a s they show that an elevation o f temperature ispro duced thro ugh irritation, direct o r reflex, o f the musc les . It is

,

however, n ot pro ved that a similar elevation o f temperature can b e

exerted reflexly by the irritation o f sensory and vaso -m o tor nerves . Thecurves presented by the temperature in the various experiments arenext c omm ented o n . In some instances there was steady and to lerablyregular rise ; after the injection o f water there was a single markedrise ; and in o ther in stances, espec ially after the injection o f putridfluid

, pus , and starch o r charc o al,there were two marked elevations .

It is probable that in al l the experiments the same cause pro duced therise

, and that this was in all cases called forth and regulated by the

314 REPORT .ON SURGERY .

well as o ther substances) depress and even destroy the regul ation o f

heat, and hence arise the longer duration and greater intensity o f theelevation o f temperature after the injections o f these than after that o fwater. If the resp iration and insulation be greatly lowered at a timewhen the pyrogenic ac tion i s still powerful , death is attended with a ri seo f temperature . If

,on the o ther hand

,the pyrogenic agent paralyse

the regulating apparatus o f temperature befo re the heart and lungs fail ,then the temperature falls rapidly, and there ensues a state o f vita

mininna recognisable only by a few respirations and by dimin ishedaction of the heart, the temperature o f the bo dy falling to a level withthat o f surrounding o bjects . 1 2 . In the last cha ter Bill ro th discussesthe question ,

In what way is fever excited by i mmato ry ro cesses P

Acco rding to Zimmerann, the combustion in the seat o f ,i mmation

is the source of the excess of heat which becomes distributed over thebody . According to this hypo thesis the heat of the inflamed part shouldalways b e greater than that o f the blo od, which, however, acco rding toMo sengeil and Billro th

,is no t always the ca se . Traube and Senato r

suppo se the increase o f temperature to be due to a dim inished expenditure o f calo ric , while Leyden and Liebermeister ho ld that there is anexaggerated pro duction o f heat in fever. An o ther hypo thesis is thatthe septic substances introduced into the blo od serve as m aterials forcombustion ; the pro duction o f fever by the injec tion o f water o r o f

serum , however, renders this impro bable. If the ordinary do ctrine beaccepted, that increased temperature in fever is due to an exaggerationo f the normal calorific pro cess, the question arises

,How is this brought

about P—in what way do es the lo ca l inflammation exert an influence on

the apparatus which regul ates the production o f heat In spite o fthe

experiments o f Breuer and Chrobak, Billro th does not adm it that irritation o f the senso ry o r o f the vaso -m o to r nerves pro duces fever byreflex action . The hypo thesis which appears to him m o re probable is,that matters are carried from the inflamed o r sloughing part into theblo od, and act on the nervous system in such a way as to impair itspower of regulating the production of heat . Billro th does not admit


pro tected against putrefactive changes . Asb eyond the immediate limit of the wound, formIng a

absces s,this must be o pened ; and, on the es cape o f the

swelling and the fever dim in ish . This o pening canno tso on

,as it is imp o ssible to know whether the case is

simple phlegmon o r o f rap idly spreading gangrene. N0 o thercation in the o rdinary c ourse of a gunsho t wo und p o ints to an

p o isoning so strongly as the acute septic phlegm on . When th

o f the wound is lined with granulations, these fo rm a barrierthe abso rption o f putrid m atters under such c ircum

plications arising from putrescen ce o f pus . Hueter believesdiphtheritic disease o f the wound (inc luding ho spital gangrene)erys ipelas arise from this s ource . In the early stage of progresswound, vibriones are pro bably the cause o f the putrefactive proThey canno t exist in fluids rich in o xygen (o f which the action o f per

manganate o f po tash gives pro o f) . Their ac tion on the living tissuesis probably prevented by the o xygen c ontained in these . In pus

c ontain ing o xygen there appear an imal o rgan ism s belonging to the

genus M onas crep usculu/m ; in a chem ical sense,these are sources o f

putrescence, inasmuch as they c ause the breaking up o f the m o re c omplexcombinations . These m onads pro duce irritation and inflamm ation o f

the living tissues . As they can live in oxygenated fluids they m aypenetrate in vast numbers through the finest lymphatic passages intothe blo o d, and may even appear in the urine . Hueter believes thattraumatic diphtheritis and erysipelas are produced by the wandering o fthese m onads into the l iving tissues . These speculations o f Hueterderive increased impo rtance from the researches o f von Recklinghausen ,

who,at a meeting o f the Physico -medical So c iety o f Wiirzburg in

June, 187 1 , ascribed to the development o f parasitic organ ism s thepresence o f multiple small purulent depo sits in the lungs, kidneys ,Spleen , liver, heart , brain ,

and eye, which c o rresp ond with what hadbeen described by Virchow as capillary embo la . The o rgan isms weretho se described by bo tan ists as schizomycetes , zo ogloea, o r m icro co ccusand are distinguished from the detritus o f tis sues by their unchangeability in acetic ac id

, glycerine, and so lution o f so da . They seem in all

es sential characters identical with the o rgan ism s described by Buhl,Oertel, and Nassilo ff as o ccurring in di htheria , and by Klebs inpyelonephritis . They o c cur, no t only in tihe blo od-vessels

,but also in

the alveo li o f the lungs and .in the urinary tubules . They were muchles s abundant in the arteries than in the veins . The absence o f

changes in the endo cardium contradicted the idea o f an embo lic o rigin .

Recklinghausen showed these purulent depo sits with m icro c o cci inpyaem ia , typhus, and phthisis, with hec tic o c curring four weeks afterdelivery, in cases

,therefo re, where previous les ion o f tis sues had

affo rded an Opp o rtunity fo r the intro ductio n o f germ s . Small myoc ardial and nephritic depo sits with m icro co cc i were fo und in the bo dyo f a b oy, eleven years o ld, who died at the end o f three days with

FEVER AFTER siJRGICAL OPERATIONS .

Symptoms of articular rheumatism , without any injury o f the tis sues .Ac c ording to Hueter the mo st s imple result o f the decompo sition of

pus is ulcerative destruction o f the granulations, which manifests itselfas diphtheritis, and, in an extreme stage, as ho spital gangrene. Diph

theritis in its m ildest fo rm may be successfully c ombated by the use o f

in the proportion o f one part in} twenty, applied fourHueter prefers the watery to the o ily so lution . In

inflammation attacking the areo lar tissue, spreadingrednes s and swelling, and leading to the fo rmation of

isions must be m ade and the tracks o f the wound freelyirrigated . In the pulpy and gangrenous fo rm o f traumatic diphtheriaHueter prefers the actual cautery to all o ther treatment . He believesthat while the cautery destroys the m onads

,its ac tion extends beyond

the tissues that are burnt . Much may b e done, in Hueter’ s o pinion,

to prevent erysipelas by the use of disinfectant dressings . He praisestar as a means o f arresting the extension o f erysipelas ; it is appliedin the fo rm of an o intment c onsisting o f two parts of tar and one o f

lard,which is energetically rubbed in with the hand fo r four hours, and

repeated two o r three times . O ther o bservers,however, have failed to

find this method eflicacious even tho ugh the inunction has been repeatedtwenty tim es .Fever fo llowing swrgica l op erations

—Mr. Spencer Wells has givensome c linical lectures on this subjec t Med. Times and Gazette,’ Jan .

2 7 and April 2 7, In the first lecture he m entio ns three casesin which h igh temperature and o ther signs o f fever were c learly dueto inflammation and suppuration o f o varian cysts

,or to decomp o s ition o f

the fluid c ontents o f the cysts,where the fever subsided alm o st imm e

diately after the remo val o f the cysts,and the patients c omp letely re

c overed. In all these cases the fever was o f the type now c omm onlytermed pyoemic . He then mention s a case o f what m ight be termedurwmic fever in a patient, set. 16

,adm itted with what appeared to be

an o varian tum our . An explorato ry inc ision was made, and Mr. Wellsat o nce came upon the caecum

,its appendix and the ascending c o lon

which had been pushed fo rwards by the cyst behind. He then knew(what was suspected before) that it was a case o f hydronep hro s is . T he

cyst was tapped and twelve pints o f fluid remo ved. The opening inthe cyst was fastened to the abdom inal wall . Befo re the operationthe temperature was afterwards it ro se to and

at the end o f ten ho urs—a rise o f 5°in ten hours . T he mo rn

ing after the operation the temperature was lower and she seemedbetter

,then it ro se again ,

m o re fluid was let o ut and a glass tube wasinserted. On the sec ond day, the temperature ro se to 104

°

2°in the

m o rning, and in the night . The third day in the afterno on itro se to and at n ight it was She lived till no on o f the

fourth day, her temperature fo r some hours having been upwards o f

Mr. Wells says, Two very puzzl ing questions fo llow—Firsthow did the operation check the elim ination o f urea in this girl andlead to its presence in excess in her blo od, o r to the ammonia resultingfrom the dec ompo sition o f urea ? and secondly, how does uremia leadto fever heat or hyperpyrexia The po st-mortem showed the left

RE PORT ON SURGERY .

kidney was almo st useless,and the

a cyst ho lding twelve pints of fluid.

selves befo re this cyst was emptied,

Trauma tic erysip elas .—Wilde states (‘Deutsches

x) that he was led, on the recommenda tion of

am ine the efl’

ect o f subcutaneous antiseptic injectiob ourho o d o f the affected part . He used fo r this purone part o f sulpho carbo late of soda into five injec tions (each 38 grains) o f thisdifferent po ints around the diseased partfive cases, on the first day, the temperaevening on the next day (two injec tio ns

oedema alone remained. WieH osp ita l gangrene

—Duringthe wounded in the hOSpitals o fgangrene were transferred to spthe care o f Dr. Jac o b Heiberg,l ished in Virchow ’ s liii

,the result

him from September 1,1879 , to March 15 , 187 1 . In all the Berlin

cases the gangrene was o f the ulcerative fo rm it was always o f lo calo rigin, although there were cases where the a erture o f entry wassmall, in which the disease c ommenced in the eep

-seated parts, andproduced c onstitutional disturbance befo re it was detected. In an

o pen granulating wound the granulations woul d break up o ver roundo r angular patches, which gradually increased, and at last became c on

fluent . The wound assumed a yellow grey co lour ; and here and therewere spo ts of a c lear red, or brownish-red co lour, the result o f effusionof blo od into the granulations . T he who le surface became ex

cavated the destructive pro cess then seized on the subcutaneousand intermuscular c onnective tissue, and the skin was Often deeplyunderm ined to a much greater extent than was visible externally. The

skin swelled first at the margin, becoming tender and red . In a c icatrix the pro cess o f destruc tion went on in small segments . The

muscles, nerves, bones, and arteries were at last laid bare, c o vered witha firm greas mass

, o r with a yellow-green stinking pulp .‘

The largecavities o f t e body were no t found invaded in any case

,and gangrene

seldom appeared on the trunk . In eighty-n ine cases under o bserva .

tion, sec ondary haemorrhage o ccurred in seven . In six of these it too kp lace from arteries, and in one it was capillary. In two cases repeatedarterial ligatures were applied, but bo th died. In the remaining cases

REPORT ON SURGERY .

centimetres in lengththeir extremities , s o as to fo rm a

small tube o pening into the external wall . The internembraces the vertical portion o f the tracheo tomy-canula .

when inflated within the trachea, thoroughly plugs thecanula and

p lug .

“ Athe inflatin

o f a smalla raised shouldsim ilar sho uldertained between tis prevented frotracheo tomy is perfo rmed, a suffic ientlycanula and tampon (c o llapsed) inserted,The anaesthetic is adm inistered by a

japanned tin . Its outlet is furn ished with an india-rubber tube, stiffened by a Spiral wire, which , by means o f a co ne-shaped no zzle

,fits into

the external aperture o f the tracheo tomy-canula. Over the inlet o f thefunnel a raised, wire frame c o vered with dim ity is placed

,and on this

the anaesthetic is dropped. A c ircle o f small ho les drilled round theedge o f the funnel ass ists the adm is sion o f fresh air. After the Opera

tion, before the remo val o f the plug, the larynx should b e washed o ut

with warm water, and the clo ts remo ved through the upper angle o f the

inc is ion by mean s o f a syringe with a fine n o zzle. A c omm o n tube isinserted till all danger o f haemorrhage has passed way. Med. Timesand May 4 and 2 5 ,In the ‘Berliner Klin . fo r September 2

,1872 , Dr.

Heiberg, o f Christiania, relates a case, in the prac tice o fDr. S cho enbo rn,in which this plan was fo llowedwith go od results . T he patient

, a man,set. 36, had cylindroma o f the upper jaw . By fo llowing Dr. Trende

lenburg’s method, it was found p o s s1ble to ma intain complete anaes

thesia throughout the o peration . In this case, however, the indiarubber tampon was not suffic ient to prevent the entrance o f blo od intothe larynx, and it was necessary to introduce plugs o f wedding fromthe mo uth . The patient was discharged cured on the twentieth dayfrom the o peration .

B ro ncho tomy .—Mr. Prescott Hewett gives a c lin ical lec ture on the operations on

the w indp ipe. Brit. Med. Jan . 2 7,

Laryngotomyfor remo va l of a ha lf sovereign imp acted in the larynx.

Mr. H . Sm ith records the case o f a tipsy Shoemaker,who put a half

so vereign in his mouth and it disappeared. Dr. Jo hnson saw it withthe laryngo scope impacted between the vo cal c ords transversely, itsreverse lo oking upwards . It was found impo ssible from its po sitionto grasp its edge. Mr. Sm ith perfo rmed laryngo tomy, and, after a

little trouble, extracted the foreign b ody . A view o f it,in s itu

,is

given . Brit . Med. Jan . 7, 1871 ,F oreign body in the larynx ; remova l—A female child

,aet. 18 m onths ,

had been suddenly seized with difficulty o f breathing five days previously. It was no t known that a foreign body had entered the larynx,

FOREIGN BODIE S IN THE LARYNx—TRACHE o TOMY . 321

but tracheo tomy was perfo rmed high up . Something was felt, and on

cutting through the crico id cartilage a dress-ho ok was found attachedto One o f the vo cal c ords . After much trouble the ho ok was removed.

The child died on the seventh day, probably owing to the damage necessarily caused by the rem oval o f the awkwardly and firm ly fixed ho ok .

”

glue patient was in the Ormond Street Ho sp ital . Lancet, ’ Sept . 30 ,

187 1 ,A case in which a fo reign body was remo ved from the larynx o f a

child eight years o ld is reco rded by Dr. Bennett . T he child had swal

lowed a p lum -stone . Tracheo tomy was performed, but the stone c ouldnot be found, no twithstanding careful search with pro bes by himselfandMr. Butcher. After some days it was c lear it was impacted b etween the c o rds . The thyro id cartilage was divided and the sto neremoved, about three weeks after the child first came under care . The

child rec overed vo ice,the Dub . Quart . J Aug . 187 1 ,

Mr. Teake records the case o f a man who , while drinking, sucked a

thin p late of bone into his larynx . E xam ined with the laryngo sc ope thebone was seen to be a long, thin p iece, impacted between the thyro idcartilage in front and the aryteno id behind. It was seized with fo rcep sby Mr. Teale

,but it c ould n ot be rem oved. Tracheo tomy was then

performed. Representations of the bone are given . Brit . Med .

Jan . 7, 187 1 ,Mr. Stokes says , As I am not aware of any case in which the dith

cult and hazardous Operation o f tracheo tomy, p erformed twice on the

same subj ect, has been rec orded, the particulars o f the fo llowing one

must,do ubtless

,be c onsidered o f much surgical interest :

The patient was a woman , set. 30 , who suffered from syphilitic disease o f the larynx . Fifteen m onths previously she had had tracheo tomyperformed. The tube was only worn a sho rt time, the wound healed,and the patient becam e free from all laryngeal distress . Six weekspreviously the difficulty o f breathing had returned. A second operationwas performed, but with great difficulty . Mr. Stokes found Langenbeck ’ s double tracheo tomy-ho o k o f great service. She c ontinued towear a tube afterwards . Dub . Journ . Med. Dec . 1872 ,Dr. Buchanan, in the Brit . Med. J March 4 and 2 5 , 187 1 ,

gives an abstract of results o f thirty-nine cases in which he perfo rmedtracheo tomy .

Dr. E ben Watson narrates two cases fo r chronic laryngeal disease .

In one, the patient fa inted during chlo roform inhalation ,and was

brought round with difficulty ; he fainted without chloro fo rm ,and

finally was found dead in bed, probably having fainted when no a ssist

ance was at hand. Dr. Watson po ints out the bearing o f such cases inthe admin istration o f chlo roform . In the second case no spec ial c omplication existed. Dr . Watson do es no t lay much stress on the part o fthe trachea opened, but he recommends sparing use o f the edge o f the

kn ife after the skin has been divided. He remarks on the length o f

time the tube should be wo rn . Lancet,’ Aug. 3 , 1 872 ,Tracheotomy

-tube removedfrom the trachea—A case, in wh ich a tubeslipped into the trachea, owing to the separation o f the shield, is re

corded in the ‘Lancet, ’ Jan. 2 7, 1872 , 1 13 . It was remove

z

d

l

by

392 REPORT ON SURGERY i

Ho lthouse,by enlarging the wound and plac ing the patient in a p

po sition .

Dr. J . W. Ogle and Mr. H . Lee rec o rd a case o f tracheo tom

which the tube, having become detached from its shield, escapedthe trachea, and was rem o ved by a sec ond o peratiafterwards . Med. Times and Sept . 2 1 , 1872 ,P aro titis tonsil litis ; tracheo tomy

—Dr.

details 5 cases which have c ome under his own care,or

his c o lleagues , in which section o f the cartilages o f the 1perfo rmed fo r the rem o val o f growths . The first casegirl , nine years o f age , who was adm itted into Guy ’surgent dyspnoea . Tracheo tomy was perfo rmed.

next four years she was repeatedly seen, but no

nation c oul d be satisfactorily carried out. But a

Mr. Durham succeeded in Obtaining a view o f th

blo cked up by warty growths . Sho rtly afterwbeen admmistered through the tracheo tomymade

,with a curved, sharp -

p o inted knife, straificial structures , the cric o -thyro id membrane and the mucousbrane o f the larynx, and then directly upwards in the m iddlethro ugh the thyro id cartilage, &c . , thus dividing all the Structur

o ne incision as high as the thyro -hyo id m embrane, which wasslightly cut. The cric o id cartilage was subsequently divided into give m ore ro om . When the edges o f the wound were drawnit was seen that thefew smal l ones werm o ved ; some were cut o ff with sc issors , o thers were twisted o ff withforceps . The wound was c lo sed with sutures and strapping . Thenext day the patient c ould breath through the larynx and couldpro duce audible sounds . On the seventh day the wound had hea led.

On the tenth the canula was rem oved after having been wo rn fo r fouryears . Mo re than four years after the operation the patient was afine

,thoroughly healthy woman , breathing, Speaking, and singing as

though she had never had anything the matter with the larynx . Thesec ond patient was a lad, aged seven years . Tracheo tomy had beenperfo rmed n ine years previously . An inc ision was made gradually fromabove downwards , through all the struc tures as low as the o pening inthe trachea. The who le larynx was full o f growths, which extendedabove and below the vo cal c ords . All were remo ved. He reco vered

,

and nine months afterwards was repo rted breathing well and the c on

dition o f the vo ice was satisfac to ry . Difficulty was experienced inc lo sing the o ld tracheo tomy wound in this case. It was finally aecomp lished after paring the edges . The third patient was a girl , agedeight years . Four years befo re, tracheo tomy had been perfo rmed. A


thyro id membrane and subsequently to c ontinue the sand downwards as far as neces sary . Cas es in whichsions have been made have pro ved a s suc c essful as tho sthyro id only has been divided. It isno t already been performed, to insert a canula during theand leave it in fo r a few days at any rate . If the growthsc ertain cases , it may no t be necessary to leave the tube in .

o f Mr.Durham ’s c onsideration o f the subject shows , 1 st .

dangers and difficulties attending o perative pro cedures arenumerous nor s o c ons iderable as have been represented and

suppo sed ; and, 2ndly, that the suc ces s hitherto achievedm arked and s o indisputable as to justify and encourage,case as may seem appropriate an earlier, bo lder, and q

m ore

to this metho d than has hitherto prevailed. Med. C

vo l . lv, 1 7In a m o stzcompletethoroughly into the

growths . He detailsalso gives a res

which growths

sequence o f the diseasedlong, slender canula waslower Open ing the plu

the granulations surroun

trachea fromlike cartilageintro duced.

utter soundstin were rem

b e dilated to the extent o f centimetre ;

DISEASE S OE JOINTS, ETC. 325

removed with go od effect ;free, as there was pares is o f

which yielded, however, to the application o f elec .

fo r s ome time . The canula c ould no t b e rem o ved, ashours fo llowed by renewed shortness o f breath . The

gained the power o f walking and ascending stairsc lo sed ; and in time she learned to introduce bougieshe glo ttis .

s narrates some interesting casesOf necro sis o f the ends o f bones leading to j o int disease, and in whichafter the rem o val o f the sequestra the latter subsided. A b oy, set. 1 1 ,was adm ittedwith disease o f the left knee fo llowing necro sis of the endo f the femur. He also suffered from necro sis o f the lower end o f theright tibia . The disease probably fo llowed on an attack o f rheumaticfever eleven m onths previously . The knee was much swo llen , was

c ontracted,and there were sinuses . After five months’ residence inlthe

ho spital at Margate, Mr. Treves made an incision below and on the

inner side o f the j o int, and rem o ved in three fragments a large seques trum

,which had become separated from the lower end of the femur.

It was between two and three inches long, and ab out an inch indiameter, and c o rresponded to the lower third o f the shaft of the

femur ; passing downwards it had been discharged through the c on

dyles and the knee-j o int . Reco very with useful limb fo llowed.

Sequestra had previously been remo ved from the tibia on the innerside . A b oy, set. 7, had disease o f the knee and a sinus in the poplitealspace, probably o f twelve m onths ’ duration . After ab out nine m onths ’residence

,Mr. Treves remo ved a sequestrum from the back o f the outer

c ondyle o f the femur . T he b oy was discharged able to walk on the

l imb . A b oy, set. 10, was adm itted with disease o f the hip . A s inus,

on the front and outer side,led to bare bone. At the end o f ab out

nine m onths a sequestrum was remo ved from the inner side o f the

j o int,the sinus having passed under the femo ral vessels and opened on

the inner side . The child did well . A b oy, set. 7, had disease o f the

ankle. After seven m onths a sinus on the outer side was enlarged,and a small sequestrum ,

which had separated from the lower end o f the

tibia towards its fibular side, and lay in c ontact with the jo int, wasremoved through the j o int . Four months later the child c ould walkwith ease . The average time required fo r the separation o f the

sequestrum was about eighteen m onths . Lancet,’ Nov. 18,187 1,

1 2 .7Disease of j oints from continued rest.—Dr. Menzel writes on thissubject in the ‘Archiv fiir Klin . Chirurgie, ’ 187 1 . He remarks thatClo quet and o ther authors observed some tim e ago that ankylo sis wassometimes the result o f pro longed disuse of jo ints . The earlier stageso f the c ondition ,

o f which ankylo sis is the term ination,were first

Observed by Teissier and Bonnet, in the examination of six individualswho had suffered from fractures o f the lower limbs , and had therebybeen prevented for long perio ds from using the jo ints . They found inthe j o ints blo ody syn ovia, swelling, serous infiltration o f the syno vialmembrane, and ulceration of the cartilages . Menzel has tested the


c o rrectness o f the

the extrem ities o f

been described by Btation in the j o int . T he synovia c ontalned numerous rand ep ithelial cells ; and the cartilages were founde to hapro liferation o f the nuclei, with c onversion into a fibrous tissuespindle-shaped cells . Menzel c onc ludes that the retention o f the

articular surfaces in c ontact by m eans o f the surrounding elasticstructures has a m ischievous effect ; and. that the ulceration o f the

cartilages is analogous to bedsores, arising as it does from the cons tantpressure o f the same po ints against each o ther.

Hip -j o int Disease—A c linical lecture by Dr. Sayre on the treatment o f hip-j o int

disease with a description and figure o f h is own spl int fo r keep ing up extension w illb e found in the Brit. Med. Journ .

’ July 2 2 , 187 1, also Med. Times and Gazette, ’Jul 2

Dyr.Morton pub lishes a lec ture on the subject o f exc is ion in disease of the hipBrit. Med. Jan . 2 0,

Chro nic Rheuma tic Arthritis .—Numerous spec imens have b een exh ib ited by Mr.

Hutch inson Path . xq ,

L o o se Cartilages in the knee-j o int—Mr. Square records twenty

-four consecutiveand uns elected cases, cured, w ith out anxiety or acc ident, by sub cutaneous inc is ionBrid . Med. Sept. 2 3 ,

Mr. L ister speaks o f the rem oval o f loo se cartilages under the antiseptic dress ingBrit. Med. Aug. 2 6,

Sp ina bifida treated by tapp ing and p ressure—A child, set. 2 5 days ,

was bro ught into the San Jo sé Ho spital,in Lisbon ,

under the care o f

Dr . Camera Cabral, on No vember 2 1 , 187 1 . It had spina bifida in thelumb o o sacral region ; the tumour was 40 centimetres in c ircumference,and measured 1 7 centimetres, longitudinally, and 10 transversely . Itwas transparent and fluctuated, but appeared to c ontain so lid matter aswell as fluid, Convulsions were no t produced by manipulating thetumo ur

,no r was there any paralysis o r o ther Sign o f injury of the

nervous system . On the 2 9th it was tapped by mean s o f Dieulafoy ’saspirato r, and 409 grammes o f yel low

,transparent fluid, c ontaining

much albumen, were remo ved. Compression by means o f adhesiveplaster was emp loyed. Some vom iting and lo ss o f appetite were theo nly symptom s that fo llowed the o peration. The tumour refilled inthe course o f a few days

,it was therefore again tapped, 2 50 grammes

o f fluid being remo ved, and on December i 4th , 42 5 grammes were drawnOff. On two subsequent o ccasions 175 and 1 2 5 grammes were removedby the aspirator ; the fluid had become m ore album in ous than it wasat first . T he last two o perations were fo llowed by meningitis, whichyielded to remedies . The child rec o vered, and was exhibited by Dr.

Cabral at a meeting o f the L isbon Medical So c iety, on February 1 7 .

O Co rreio Medic o de Lisbo a,’ March 1,

Dr. Morton reco rds a case cured by injections Brit. Med. J April 6,Ulceration of thej ugular veins .

—Dr. Gro ss writes an elabo rate paperon ulceration o f the jugul ar veins, communicating with an abscess oran o pen so re. He also alludes to the cases which have been rec orded,in which arteries have been opened by ulceration

, &c .

,and to Mr. Bir


been removed by a sharp scalpel . In only 2 of

c ontents o f the vein c ommun ic ate with a c lo sedflowed at o nce upon an inc ision beingmade into it .

sible to diagno se such a c ondition . In 2 , h owev

picious symptom s . In 1 there existed “a certain

perceptible bywhile, in the O

termined whetby the caro tid artery .

the presence o f venous blo od, but a careless exam ination m ight havegiven rise to the suppo sition of an aneurism . Intro duction o f air was

o nly met with in one instance. A month befo re the death o f the

patient, while dres s ing her neck, there was slight bleeding, fo llowed bya gurgling sound, &c . , and alarming sync ope, from which she gradual lyrec overed under the use o f stimulants . “ The practical lessons to bededuced from the study ’

o f the facts c ontained in this pa er are,—First ,

that acute, destructive inflammation o f the tissues 0 the neck and

deeply seated abscess,which has existed for some time and suddenly

takes on acute a ction , may, if unchecked in their progress , lay bare andperforate blo od-vessels , and that this result is to b e fearedm ore partienlarly when diffuse cellul itis fo llows grave fo rm s o f scarlatina o r o theracute spec ific diseases . Secondly

,that scrofulo us abscesses and ulcers

are no t always indo lent, but may, under favorable c ircumstances, thatis

, in an enfeebled, broken-down c ondition o f the system ,rapidly as sume

a phagaedenic condition , and lead to the same complication . And thirdly,

that the large arterial and venous trunks are m ore liable to b e invo lvedthan their branches . ” Inc is ions should b e made early to check theinflammation . If the surface o f the so re be unhealthy, chloride Of zincin so lution, &c . , m ay be used. Po ultices should b e avo ided. If the

gangrenous action be extensive and spreading, the ho t iron may be

lightly app lied. The general c ondition o f the patient must be attendedto . As to the treatment Of the haemo rrhage little can b e said

,as all

the cases pro ved fatal . In all the cases in which it is po ssible to applya ligature, and the disorganized c ondition o f the parts do es no t c ontraindicate its employment, it should be reso rted to in preference to o therhaemo static agents . It is perfec tly safe, and is no t o pen to the Objections which can be justly urged against c ompressionfi“ In the casesdetailed the latter was utterly ineflieient . If it be tried it should be inthe fo llowing way z—An assistant ’ s finger should be placed above thewound, a small p iece o f sponge shoul d be held in c ontact till it adheres tothe o rifice, and should then be supported with a compress and adhesivestrips . Instead o f the sponge, a piece o f lint dipped in dilute so lution Of

persulphate o f iron may be employed. This W111exerc ise a benefic ialinfluence in checking gangrenous ac tion and co rrecting the Offensivedis charge . Am . Journ . Med. Sc iences, ’ April, 187 1 ,I ntrabueea l resection of the inferior maxil lary nerve—Dr. A Menzel

,

o f Vienna , describes in the Archiv fur Klin . xiii,two cases in

wh ich resection o f the lower maxillary nerve was performed by him and

See ‘Retrospect,’1867

-8, p . 283 , and‘Am . Journ . Med. Sc iences,’ Jan. and

April, 1867.

RESECTION or NERVE S, ETC . 329

by Dr. Billro th in the manner propo sed by Paravicini , o f Milan , in1858. The c orner Of the m outh being heldwide o pen

,an inc is ion three

centimetres long, running o bliquely from within outwards , is made

along the anterio r border o f the ramus o f the jaw through the skin and

the anterior fibres Of the internal pterygo id muscle. The c onnectivetissue between the pterygo id and the perio steum is then torn throughwith the finger, the nerve is easily reached at its entrance into the

dental canal , and a po rtion is remo ved. The lingual nerve is easilyavo ided by taking care to trace the nerve to its entrance into the bone .

In Menzel’s case the nerve was raised on a ho ok, and a piece four lines

long was exc ised. The bleeding was very slight . Billro th raised theperio steum from the b one, and having surrounded the nerve with a

thread, cut out a piece ten centimetres long. Menzel says that theintrabuccal metho d o f exc is ion of the lower dental nerve is attendedwith less extensive injury and is les s dangerous than the o ther plansthat it leaves no disagreeable results—such as scars

,fac ial paralysis

,or

salivary fistula ; that the nerve is readily rendered accessible,and may

be exc ised even to the extent o f ten centimetres ; that the haemorrhageis slight ; and that the Operation is not difficult o f perfo rmance. Dr.

Menzel refers to a case described by Dr. Meusel, o f G‘ro tha, in the

‘Deutsche Klin ik ’

for N o vember,187 1 , in which the intrabuccal

Operation was performed, but b o th the dental and the lingual nerveswere divided. He believes that this is the first case in which theo peration has been perfo rmed on the living subject . Paravic inioperated only on the dead body, and up to a recent date his propo salhad no supporters, but several opponents .Sp asm, &c .

,of the arm ; Operation exp osure and extension of the

nerves of the bra chia l p lexus ; recovery—In the ‘Lancet

,

’

Nov. 30 ,1 872 , will b e found a detailed analysis Of an ac c ount o f a bo ld Opera

tion perfo rmed by Prof. Nussbaum , which resulted in a physio logicaltriumph . T he patient was a so ldier who had been injured in the war.

He suffered from spasm o f the arm , from anaesthesia, and from pain .

Having once given relief by stretching the ulnar nerve in a case o f

spasm o f the inner fingers , Pro f. Nussbaum determined to operate on

the present case, having first o f all received a report from Pro f. Vo it asto the probable seat of the m ischief. He laid bare the ulnar nerve and

stretched it, then the nerves around the axill ary artery and stretchedthem , and lastly the c ords o f the brachial plexus . These were individual ly and vigorously pulled. The man was cured by the operation .

Dr. Gartner has Operated on ano ther patient.Transfusion of blood—Dr. Hildreth writes on the kind o f cases in

which it is useful . Defibrinated blo o d should always be used, human ,

if po ssible ; but successful cases have o ccurred with the blo od o f calves,

lambs, sheep, &c . The instrument he uses c onsists o f an india -rubberhand-ball in the centre o f two feet o f tubing. T o one end is attacheda funnel-shaped, metallic vessel , double cased, with a tube throughwhich hot water is to b e p oured between the cases

,and also a c on

venient handle. T o the o ther end is attached a metal,capillary po int

to enter the vein . Ab out five inches from the po int is inserted a shortsegment of glass tubing, in order that it may be known when the


supply of blo od is exhausted, and to avo id injecting air. If the

is held up , the blo odwill usually flow ; if no t, the hand-ball can b(Am . Journ .

Dr. Winants recordscaro tid artery o f a lambdefibrinated. The patinight . At the time heDr . Aveling records

the blo od.

rubber portion Of the apparatus filled with water aflixed, ano ther tubehaving been inserted into a vein in the patient’s arm

,as was thought .

It pro ved to be only in the cellular tissue, andwas then properly inserted.

S ixty drachm s of blo od were injected. The patient rec overed c om

pletely. A diagram o f the who le metho d o f Operating is given . Abevel-po inted, silver tube is inserted into a vein o f the patient, and thistube is filled w ith water, and the thumb is kept on the o pen end. An

assistant prepares the blo od-donor’s arm, and inserts a round-po inted

tube in a direction towards the fingers . An indie-rubber tube with a

ball in the m iddle and a tap at either end is filled with water and fittedto the two tubes . T he taps are turned on, the india-rubber tube c om

pressed On the donor’s s ide o f the ball , and the ball squeezed to send

the water on into the patient ’s vein . Next the tube is c ompressed o n

the o ther side o f the ball, and the latter filled. The pro cess is repeatedas at first . Defibrination is no t necessary . Lancet,’ Aug . 3 , 1872 ,

ation of Syme’

s rhinozylas tio op eration—Mr. Stokes Operated

on a man, set . 39 , a Sc o tchman, who was suffering from comp lete destruction o f the nasal bones as well as the nasal pro cesses o f the superio r maxillary bones , and the so ft structures co vering them . Therewas a large o pening, through which three fingers could be easily introduced into the nasal cavity . Fo rtunately the soft parts constitutingthe tip o f the no se remained intac t, and the tissues around the openingappeared healthy . Mr. Stokes adopted a m o dification o f several proc edures . He made two triangular flap s, with their apices ab o ve, at thenasal pro cess o f the o s frontis and their bases below and having freelyvivified the edge o f the large, o val-shaped opening he transplanted thetwo triangular flaps towards the m iddle line s o as c ompletely to co verthe opening and united them in that situation with fine entomo logistpins and twisted, glass silk sutures . The bases o f the triangular flapswere in like manner united to the upper margin Of the lower portion o f

the no se . In o rder to fill up the defect at each side o f the innerportion o f the cheek

,where, namely, the flaps had been taken,

ano therplastic Operation was perfo rmed. The flaps were made of a somewhatquadrilateral fo rm and were taken from the soft parts c o vering themalar b one . The result was satisfactory . A wo odcut Of a pho tographis given . Dub . Journ . M ed. Dec . 1872 ,Zeis

’

oheilop lastio Op eration—Mr. Stokes rec ords a case in which he

performed this Operation . He remarks that it is best adapted fo r caseswhere the disease extends acro ss the who le o r greater portion o f thered border o f the lip . Its advantages are s implicity and facility o f


the free detachment Of the remainder from the subjacent partsfact that the apparatus was kept on fo r a very long t1me (it wasOff at night) the repression o f the granulation s and the free divi

pro ofmaterial interpo sed nextthe outmo st fo ld also a piece Ofwaterpro of material i s in serted to m akeany discharge travel through a quantity o f the gauze . The gauzeadm its air freely, but remo ves the septic germs . E din . hi ed.

Aug. 187 1 ,Os sifi oation of the marrow of bones .

—At a meeting Of the AcademyOf Medic ine in Paris on January 9th, 1872 , M. Demarquay presenteda spec im en o f o ssification o f the m edulla o f the humerus . It wastaken from a young man

,set. 2 0 , who had had his humerus fractured

by a gunsho t a year previously . An attempt was made to preserve thethe limb

,but the wound did no t heal ; numerous abscesses formed on

the chest, and the arm became greatly swo llen, and presented, throughits who le extent, flstulous o pen ings leading to diseased bone. The

patient ’s health being much impaired, disarticulatio n of the limb was perform ed. The humerus was divided longitudinally, and it was then foundthat the perio steum had formed a layer o f new bone c o vering the who leshaft, but leaving o penings through which the dead bone c ould bereached. The who le o f the shaft had undergone necro sis . The

medulla had undergone o ssification at the ends o f the diaphysis , itsperiphery being transformed into bone, and the central part destroyed.

S capulo-hmnera l p eriarthritis .

—Dr. S imon Duplay gives an elaboratedescription , in the ‘Archives G énérales de Médec ine’ for No vember,1872 , o f an affection which is, he says , very c ommon, buthas scarcely, ifat all , been thoroughly described in surgical wo rks . Jar

'

ava how

ever,in a paper on displacement o f the tendon Of the long hea o f the

biceps, published in the Gazette Hebdomadaire , ’ in 1867, gives a veryaccurate acc ount of the early stages o f the diso rder. He says that c ontusions o f the shoulder and sprains o f the arm are very Often fo llowedby inflammation o f the subacrom ial syno vial bursa, produc ing the fo llowing symptoms —A sensation at the time o f the acc ident as if something were displaced ; tumefac tion o f the shoulder ; pain, preventing themovements o f the arm, especially abduction ; flexion o f the forearm on

the arm,and rigidity of the biceps musc le ; increased pain, with crep ita

tion beneath the acrom ion when the arm i s raised and abducted, anddisappearance o f the pain and return o f the power Of m o vement afterrest and the use o f a sling, with the application o f lo tions to theshoulder. This description o f Jarjavay is app licable to the acute form

,

but Dr. Duplay has extended his researches also to the chronic form o fthe affection . After describing the symptomato logy, diagno s is , progno sis, and treatment, and giving several cases, he sums up in the fo llowing conclusions Direct or indirect injuries of the shoulder are

SCAPULO-HUMERAL PERIARTHRITIS . 333

o f the tissues surroundingarthritis is mo re espec iallyand the subdelto id areo lar

tissue, and gives rise to thickening and induration o f the areo lar tissueand o f the walls o f the subacrom ia l bursa, and also to the fo rmation o f

adhesions and fibrous bands, which impede o r entirely prevent the headOf the humerus from gliding on the c oncavity o f the acrom ion and the

inner surface of the delto id. (2 ) Periarthritis is distinguished fromdisease o f the interior Of the sho ulder-jo int by the absence o f deform ity

,

and if there be any swelling, it is only in the acute stage, when it i slimited to the summ it o f the shoulder. The characteristic symptom s ofperiarthritis are the fo llowing -(a) The m o vements o f the shoulder areimpeded, sometimes to such an extent that the arm canno t b e extendedhorizontally . In all the m o vements of the j o int the relations o f thehumerus to the scapula remain unchanged, and the latter bone playsround its c lavicular attachment . In some cases these m ovements areaccompanied by crepitation . (6) There is pain o n m oving the arm ,

not

at the level o f the articulation ,but beneath the acrom ion

,at the attach

ment Of the delto id to the humerus . Pain is also caused by pressurebelow the acrom ion , at the level Of the c oraco id pro cess . Sometimes,also , there is a sensation o f tingling and o f numbness along the limb asfar as the hand. (0) The forearm is sometimes semiflexed, and at

tempts to extend it pro duce pain in the fo ld of the elbow and in the

neighb ourho od o f the c orac o id pro cess . (3 ) Periarthritis o f the

sho ulder must be carefully treated at its c ommencement, if we wouldavo id the rigidity to which it gives rise. Gymnastic exerc ises of thelimb

,electric ity, do uches , and shamp o o ing, are the best m ethods . (4)

In cases o f chronic periarthritis the only means o f pro curing a rapidand c omplete cure is at once to break down the adhesions and the

fibrous bands . The use o f chloro form is indispensable for this o peration, which may require to be repeated if the result be n o t satisfactory .

5 ) After the adhes ion s have broken,the patient must be placed for

some time under a c ourse o f gymnastic exerc ises , electric ity, douches,&c . , until the limb has regained its p ower o f m ovement.P erio s titis of

“

the temp o ra l bone .—In an interesting c linical lec ture

on this subject , in relation to a case in the London Ho sp ital, Mr .Hutchinson calls attention to the fact that the bone is n o t c o vered o n

its o ppo s ite surfaces by the same perio steal membrane. Necro sis isvery c ommon in the long bones, but Of the temp oral bone it is c omparatively rare . We have perio stitis o f this bone ac c ompanied by c on

siderab le suppuration , and yet fo llowed by c omp lete rec o very withoutthe death o f any p o rtion o f b one . This m ay be due to the c op ioussupply o f blo o d which it Obtains . The c omparative immunity o f theinner surface o f the b one from inflammation may po ssibly be attributedto the absence o f c ontinuity between the dura mater and the externalperio steum . The treatment reso lves itself, mainly

,into the po ss ibility

o r impo s sibility Of o pening the abscesses which form in c onnection withthe inflamed perio steum . This can be accomp lished o ver the masto idpro cess

,but no t if the abscess po int in the meatus o r in some part o f

the pharynx . (‘Med. Times and Nov. 2 5,


Treatment of persistent inflammation—Mr. John Marshall wrthe emp loyment o f so lutions o f the o leates o fmercury and o f

the lo cal treatment Of persistent ” inflammation . They c onsist,tial ly, o f so lutions o f o xide Of mercury in O leic ac id, being,the Oleate o f mercury disso lved in Oleic ac id, but to these sadded a certain quantity o f m orphia , which, in its unc ombinreadily so luble in , and doubtless unites with , the Oleic ac id.

of m ercury prec ipitated by caustic po tash o r soda from a

the metal in n itric ac id (which is a yellow impalpable powder) is, whenrecently made and well dried, readily so luble in Oleic ac id

,especially

when aided by a temperature o f about 300° Fahr . The so lutions are

named according to the amount o f oxide they c ontain . The 5 perc ent . is a perfectly c lear, pale, yellow liquid. They should no t be

rubbed on the skin, but merely smeared on . As a rule, from ten to

thirty drops are suffic ient for one app lication . This should b e repeatedtwice daily fo r four o r five days, then at night only, then every o therday. In a case o f chronic inflammation o f the knee-j o int treated

,

twenty to thirty drops of the 5 per cent. so lution also c ontaining a grainOfmo rphia in the drachm were applied night andm orning for about tendays

,and then at longer intervals . A p iece of linen was kept on the

j o int, then a layer o f c o tton wo o l , and o ver this a bandage from the

fo o t to above the knee. The patient c ould walk at the end of a month .

The 5 per cent . so lution with the addition o f an eighth part o f ether isuseful in syc o sis, chloasma, and o ther fo rms Of tinea . It destroyspediculi and their ova . In congenital syphilis a drop Of the 2 0 per

cent . o intment, about the size o f a pea o r bean, placed in the child’saxilla night and m o rning fo r five o r six days is an efl

'

ective and c leanlymeans o f treatment . Lancet,’ May 2 5 , 1872 ,Treatment of ep is taxis .

—Dr. F . Kiichenmeister,o f Dresden

,propo ses

to treat epistaxis by an instrument which he call s the rhineurynter, ”and which is

,in fact, an im itation Of the c o lpeurynter . ” It c onsists

o f an india-rubber tube about 2 0 o r 2 4 centimetres long, with a diameter Of half or three-fourths Of a centimetre

,and ending in a bulbous

extrem ity ab out 15 centimetre long and from 1 to 1 4} centimetre wide .

The tube is guided into the no strils by means of an ordinary sound,and

,the latter be ing withdrawn, air or water i s injected so as to distend

the bulb , which thus fills the naso -

pharyngeal cavity and presses againstthe walls o f the nares . Oster. Zeitschr. fur prakt. NO . 2 2 ,

N asal mucous membrane used in uranop lasty .—M . Lannelongue com

municated to the Surgical So c iety o f Paris, in May, 1872 , the histo ry o fthe case o f a lad, set. 1 7, who had c ongenital fissure o f the hard andso ft palate. He had also harelip on the left side

,which was remedied

by Operation . The cleft in the hard palate was a centimetre in breadth ,and to its right borderwas attached the septum narium . This suggestedto Lannelongue the idea Of transplanting the nasal mucous membrane.

He acc ordingly made two perpendicular inc isions in the membrane,before and behind, jo ined the upper ends by a transverse cut, lo o senedthe flap thus fo rmed, and fastened its free border to the left edge o f the

fissure after paring the latter . Union fo llowed, and a fortnight after


inc oherent and unmanageable. There was great turgescence o f

vessels o f the right side o f the neck . On the 4th Of December thetient was so much better as to require n o further attendance .

at this time that the atrophy Of the

no ticed, though it was no t then s o

OnMarch 2 9th , 1871 , the patient wasvated degree, and, in addition ,

therether with paroxysms Of sufl

‘

o cative

times in the twenty-four hours . She c ould only put thevery slowly, and seemed unable to do s o at al l at first .was crimped and puckered along its who le right side from base to apex

,

but these appearances were m o st marked in the anterio r two thirds,

and an actual lo ss Of substance h ad taken place, s o that this half o f theo rgan seemed small and wasted . The lo ss o f substance was bounded bythe median raphe, and the c ontrast between the p lmnp nes s o f the leftside and the shrivelled aspec t o f the right was very striking.

tongue was so ft throughout there were no hard nodules on it . NO alteration was no ticed either in the c omm on sensation o f the o rgan o r in itsspec ial sense o f taste. When the tongue was pro truded there was no

deviation to either side. The paro xysms o f dyspnoea became mo re

frequent and more severe,and o n the 7th o f June, in one o f these pa

roxysm s , she died. There was no po st-mortem . Two published casesare quo ted , one reco rded by M . Dupuytren, and the o ther by Sir JamesPaget . Mr. Fairlie Clarke remarks that in his case he thinks therewas go od reason fo r suppo sing that the affec tion depended on the in

vo lvement o f the right hypoglo ssal nerve in a sec ondary c ancerousgrowth , either inside the c ran ium o r at the upper part o f the neck . The

facts which lead to this c onc lusion are—the existence o f an undoubtedcancerous tumour, which was rem o ved Sixteen m onths before death ,after it had been growing about a year ; the general cachexia ; the intense and deep -seated pain on the right side o f the head and neck the

fulness and turgescence Of the ves sel s o n the right side o f the neck ,deno ting an Ob struction to the c irculation ; the frequent attacks o f

dyspnoea and dysphagia, which probably depended on pressure on

the pneumogastric and glo sso -pharyngeal nerves . These symptoms,together w ith the absence of paralysis Of the extremities and the c learness o f the intellect, seem to indicate that the disease was no t in the

brain or medulla o blongata , and make it probable that there must havebeen an adventitious growth pres sing upon the right hypoglo ssal nerve,and implicating m o re o r less the pneum ogastric and glo s so -

pharyngealnerves . The different situations in which such a growth m ight beplaced are discussed, and the evidence which exists to show that thec ondition o f the tongue m ight depend on an affection o f the nerve its elfis c ons idered. An experiment on a rabbit is detailed. In an appendix,cases m ore o r less similar are a lluded to . An illustration Of the stateOf the tongue is given . Med .

-Chir. lv,

[Abstracts Of various papers on Cancer, Tetanus , E lec tro lysis,Treatment of Defo rm ities

,etc .

, etc .

,have been unavo idably om itted ]

RE P O R T

OPHTHALMIC MEDICINE AND SURGERY.

BY

ROBERT BRUDENELL CARTER,

OPHTHALMIC SURGE ON T o ST . GE ORGE’

S HOSPITAL.

THE years 1871 and 1872 have been marked, like tho se immediatelypreceding them, rather by writings Of a fugitive charac ter

,devo ted to

matters Of detail,than by ac c o unts Of any researches o r facts o f

striking no velty. The International Congres s o f Ophthalm o logy heldits fourth quadrenn ial meeting in London ,

in the first week o f Augus t,1 872 , but the repo rt o f the meeting has n o t been published at the

time when this summary is passing through the press, and the papersread mus t be no ticed on a subsequent o c casion .

In the c ourse Of the two years death has taken away five Ophthalmo logists o f em inence . Dr. Heymann ,

o f Dresden , best known in thisc ountry by his ingenious aut-ophthalmo sco pe ; Pro fessor GiOppi, o f

Padua ProfessorFrederic Jaeger, OfVienna ; Dr. Pamard,o fAvignon ;

and Professo r Sto eber,o f Strasburg . Of these, the first two have

died in the prime o f life the last three were veterans, already restingfrom their labours .In E ngland the literature o f Ophthalmo logy has been extremelyscanty . Mes srs . Churchill have published, in their manual series, a

sec ond edition o f Macnamara’ s treatise.

* Mr. Streatfeild has re

written the chapter on diseases o f the eye fo r a new edition o f E richsen’s Sc ience and Art Of Surgery the Ophthalm ic Ho spital Reports ’have appeared irregularly and various papers have been published inthe journals o r read before the medical so c ieties .In America the Archives Of Ophthalmo logy and O to logy’ have been

c ontinued, and a sec ond vo lume has been c omp leted. The Transactions o f the American Ophthalmo logica l S o c iety

’ have been issuedirregularly .

In GermanyDr. Hirschberg has commenced the publication o f an

anno tated edition Of von Graefe’s Clinical Lec tures ;1' Dr . Schm id

‘A Manual o f the Diseases Of the Eye, ’ by C . Macnamara.

1' Pro f. A . von Graefe’s

‘Klin ische Vortr'

age iib er Augenheilkunde. Herausgegeb en,erlantert und mit Zusatzen versehen vou Dr. J. Hirschberg,’ Berlin, A. Hirschwald.

22

REPORT ON OPHTHALMIC MEDICINE AND SURGERY .

has issued a treatise on the lymph-fo llic les of the c onjSalom on has written a tract o n the diseases o f the lentifounded o n v . Graefe

’s teaching ; Dr. Otto Becker hasedited Heinrich Miiller’s writings on the anatomy and

d to the edito rial staffOphthalmo logie,’ and the Klinis che M onatsb latter

’

have appeared as usual .In France Dr. de Wecker has is sued a French editionOphthalmo sco pic Atlas ,’ with the o riginal plates, and withtion o f his own upon the diseases o f the deeper p arts o fGalezowski has c ompleted his and

menced, in c onjunction with Dr .

thalmic jo urnal ."H' In Ho lland the u sual sc ientific papers

added to the annual rep orts o f the Netherlands Ophthalm icIn Belgium the Annales d’

Ocul istique,’and in Italy the

d’

Oftalmo logia Italiano ’ have been c ontinued with regul arity .

(a) Ana tomy and Physio logy.

Ocular tension .» -M onnik11 has published the opinions o f Don

with regard to the princ iples o f tonometry o f theo f his own Observations with an improved tonometer.

o ut that when we determ ine the o cular tension, eithe

o r by a tonometer, we estimate the force required toimpression upon the tunics o f the eye . The tension

pends upon several c onditions , and we

irectly the hydro static pressure o f the c o

that we exert upon the eyeballspace, and disp laces a po rtiontents being inc ompressible, ro om must be found elsro om is afforded (a) by extension o f the remaining partstunic s, an effect that will vary with their elastic ityif“ Lymphfo llikel der Bindehaut des Auges . Histo logische S tudie, von Dr.

Schm id, ’ W ien, 1871 , Braumfi ller.

V'

l‘Die Krankheiten des L insensystems , von Dr. Max Salomo n,’ 1872 , Brunswick,

1eweg .

I Heinrich Miiller’ s Gesammelte und h iaterlas sene Schriften zur Anatomic undPhys io logie des Auges . Zusammengestellt und herausgegeb en von Otto Becker, ’Band, i, 1872 , Leip s ic , E ngelm ann .

Ophthalmometrie, von Dr. M . Wo inow,

’1872 , W ien, Braumiiller.

‘Jahresb ericht uber die Leistungen und Fortschritte im Geb iete der Ophthalm o logie,

’E rster Jahrgang, 1872 , Tub ingen ,

Laup .

1T Traité des Maladies du Fo nd de l ’CE il et Atlas L. de

Wecker et E . de Jaeger, Paris , Delahaye.

a“ Tra ité des Maladies des Y eux,

’Paris .

1~ ~l~

‘Journal d ’Ophthalm o logie de Paris .

’

2111‘Tonom eters en Tonom etrie,’ Dissert inang ., Utrecht, 1868 ;

‘B ij bladen, 10deV erslag , Nederl . v. Ooglijders , 1869 ;

“ E in neuer Tonometer und seinGebrauch ,

” ‘Arch . f . xvi, 1 , 49 .

,j

840 REPORT ON OPHTHAEMIC MEDICINE AND SURGERY .

during the first yearsabno rmal . The auththis child, his mo ther

m ent, and gave reasons fo r attributing it to a pinflamm atio n .

T he diagnosis of co lour blindness—M . W o inow * broughtthe Heidelberg Co ngress o f 187 1 a simple and easy methodc o vering c o lour blindness . It rests

'

o n the fac t that all theinc luding white, that are distinguishable by an eye which is blo ne o f the three elementary co lours, may be o btainedtwo . Thus , if the eye be affected with anerythropsia ,it can distinguish , inc luding white and grey, m ayvio let and green . If it b e blind to green ,

all the c o l

tinguish may b e Obtained from red and vio let ; o r if

red and green . The autho r c o

imp o sed c oncentric disc s, eachlargest and lowest is c o loured vio let and green ; the sec ond, vio let andred ; the third, red and green ; and the fourth , black and white

,o r

grey . When the top is rap idly ro tating the disc s present a grey centre,surrounded by three various ly c o loured rings . The patient is a skedwhether any o f the three rings seem to him to be grey, like the c entraldisc . If one should present this appearance, the patient is blind as

regards the c o lo ur absent from that di sc .

Retina l puls ation in a ortic dis ease—Dr. Becker? read, before the

Heidelberg Congress o f 1871 , an account o f his investigations on

arterial (retinal) pul se He had

Observed,in c oncert with

he thought the Observation n

afterwards that he had been antic ipated by Quin cke, who had published two artic les up on theFurther and careful exam ination showed that in every case Of

insuffic iency Of the ao rtic valves , no t c omplicated with o ther valvulardisease, the arterial pulse was plainly vis ible, and the m ore plainly them ore c onsiderable the c onsecutive hypertro phy o f the left ventric le . Itwas absent when val vular insuffic iency was c ombined with very pronounced anaemia o r with fatty degeneration o f the heart . The pulsewas visible, not only up on the papilla

,but o ver the retinal surface,

wherever it was po ssible to fo llow the arteries with the Ophthal

m o sc ope.

The

(phenomenon is who lly difierent in its character from the

so-calle arterial pulse o f glauc oma , in which, on ac c ount o f the

resistance to be o vercome, blo od o nly enters the central artery Of theretina at the acm e o f each successive pulse wave . The visible pulse of

‘Annales d’Oculistique,’ 1872 , i, 1 1 2 ; ‘Arch . f. xv n, 2 .

1‘Annales d’O culis tique, ’ 1872 , 1, 2 75 .

I‘Berl . Klin. 1868, NO. 34 ; 1870 , NO . 2 1 .

ANATOMY AND PHY SIOLOGY . 341

cy presents all the characters that can be recognisedouch . It allows the o bserver to c o unt on the retinaheart, to see the rhythm ical distension and elongation

ach

h,all the undulations o f the curve described by the

o f the phenomena is not equally easy in all cases,o r

o f the same retina . The distension o f the arteries is bestfurcation

,their elongation in tho se which present curves in

the fo rm o f an S . During the arterial diasto le the curves o f the S In .

crease, and return to their fo rmer p o sition during the arterial systo le .

Sometimes the rhythmical and verm icular m o vements o f the vesselsc ommunicate to the who le fundus o f the eye a strangely an imatedappearance. It is well known that Sim ilar c onditions may b e ObservedIn the mesentery o f a frog. When a drop o f water is suffered to fallon the expo sed intestine, the muscular c o at, by its c ontraction , in

creases the resistance Oflered to the arteries on their pas sage from the

mesentery to the intestine,and their verm icular m ovements assume an

almo st spasm odic character.

Dr. Becker has Observed that,in a certain distribution Of vessels on

the papilla, spontaneous arterial pulsation may b e fo und even in the

no rm al eyes o f healthy pers ons . He has also observed a case o f

detachment Of the retina, in which the arteries,on their passage o ver

the displaced p ortion, perfo rmed very manifest verm icular m o vements .But his mo st interesting Observation was in a case Of aneurism o f the

transverse ao rta,in which the phenomena Of visible pulsation were

apparent in the left eye and entirely absent from the right . Thisc ondition c ould only be explained by reference to the seat o f theaneurism ,

which must have been s o situated as to invo lve the origins o fthe left c aro tid and subc lavian

,leaving the innom inate free. T he c on

c lusion to be drawn from this Is that, in certain cases,the appearance

Of a retinal arterial pulse might assist in determ ining the prec ise seato f an aneurism o f the transverse aorta .

In the discussion which fo llowed, Dr. Weber,in reply to Dr . de

Wecker, gave an account o f the retinal c irculation at and imm ediatelyafter dis so lution . Dr. Schm idt, who had taken part in Quincke’sOb servations

,c onfirmed the general ac curacy Of Dr. Becker’s statements

,

adding, however, that the force o f the pulsations varied from time totime with the degree o f cardiac exc itement . Dr. Becker rejo ined thathe was so well aware Of this that he was in the habit o f adm inisteringa stimulant to render the pulse m o re visible . He was entirely in

ac co rd with Quincke except on two po ints . That o bserver said thatthe pulse m ight b e manifest at certain m oments and quite invisible at

o thers . He also c laimed to have seen ,besides the arterial pulse, a

rhythm ical co loration and pallor Of the disc,which he attributed to a

capillaryp ulse. In spite of the mo st careful and conscientious exami


nations,he had not been able to verify either of these statements .

Schm idt o bserved that he had witnes sed bo th phen omena . Dr. Be

did n o t doubt him,but regrett that he c o uld not him self

the same thing .

Refraction—Dr. F . E rismann,o f St. Petersburgh

, publishes* a

full and detailed acc ount o f his investigation o f the state o fthe eyes o f 4358 scho lars o r students o f bo thfrom 10 to 2 4 years .

exam ination o f the diOptric state o f the eyes o f 2 40 village scho o lchildren ,

after the instillation o f atropine. He c ommenced by someo bservations on the paper o fM . E rismann mentioned abo ve, and statedhis intention o f analys ing this paper fully o n a future o c casion . Atthe time he wo uld only refer s ome express ions in it which he

thought a little to o bo ld, and espec ially to this , that the use o f c oncaveglasses was hurtful to the sight o f young myo pes . No thing c ould bem ore difficult than to determ ine

,ap riori, whether, given a certain

degree o f myopia,such or such a glass would be hurtful or no t. In

o rder to answer such a question it would be necessary to have a numbero f persons all with the same degree o f myopia , all o c cupied in the samemanner and during the same hours , and to give glasses to half o f themand no t to the o thers . Under such c onditions , and after several m onthso f o bservation

,it would be po ssible to determ ine the influence o f spec

taeles upon myopic vision .

The chief interest that Dr. Co hn found in the paper of M . E rismann

was the pro o f it affo rded o f the great frequency of facultative hypermetropia . Am ong the children attending scho o l at St. Petersburgh44 per cent . were manifestly hypermetro pic , and it m ight have beenfound that many o thers were really s o if atro pine had been employed.

The autho r wished to fill this vo id in all previo us researches ; and hehad been enabled, by favo rable c ircumstances

,to apply atropine to the

eyes o f 2 40 children at the s cho o l of Schreiberhau. He selected 142

b oys and 98 girls , al l wh o were Old eno ugh fo r his purpo se, and firstexamined them for facultative hypermetrop ia without atro pine, and

found Hm . in 77 per cent . After atro pinization he found H in 99 percent .

,and in the fo llowing degrees

1

ain 2 6 per cent. in 6 per cent.

111 2

111 1 2 l l] 1

so that the extremes were 56 and Tla

'

, and the mo st frequent grade‘Arch iv. f . xvn , 1 , 1

—79.

1“ ‘Annales d’Oculistique,’ 1872 , i, 89.

344 REPORT ON OPHTHALMIC MEDICINE AND SURGERY .

to Dr. Charles Delstanchefi“ enters at lextraction,

for which he c laim s a large propo rtion o f suc cess . He dis

p enses with a blepharo stat, and never administers an anaesthetic . He

do es no t use the upper section except fo r prom inent eyes , and prefersthe lower wherever the o rbital fat is abso rbed, o r the eye, from anycause, deeply seated. He entrusts the upper l id to the c are o f an

as sistant, wh o is to ld no t to elevate it to o much , and himself steadiesthe globe with two fingers o f the right or left hand, ac c ording to theS ide o perated upon . He then intro duces a knife, o f the general m o delo f that o f Graefe , but twenty-four m illimetres long instead o f thirty,and three bro ad in stead o f two and a half, at the junction o f the lowerwith the m iddle third o f the outer c orneal margin , and c arries it into theanterio r chamber directed towards the pup il, o r at an angle Of 40

° withthe lower ho rizontal tangent o f the c ornea . When the widest part o fthe blade has fairly entered the chamber he changes the direction o f the

p o int in such a manner as to make a c ounter-punc ture o ppo s ite thepuncture, the cutting edge being turned directly downwards . T he

c ounter'

pun cture being fully made, the cutting edge is turned forwardtill the flat o f the blade makes an angle o f 45

°or 50

° with the iris,and

then the c orneal section i s completed by a gentle sawing m ovement .The capsule is next lacerated, and an attempt made to extract the lensby simple pressure and c ounter-

pressure . If this should no t suc ceed,

o r if the iris should pro trude befo re the advanc ing lens , an iridectomyis perfo rmed, and the necessary pressure again employed. The externalinc ision may be enlarged if necessary . Six hours after the o perationthe writer drops in so lution o f atro pine, and repeats the applicationevery twelve hours , the lightly c om ressive bandage being changedeach time. After three days the ban age is laid aside, but the atrop inei s continued fo r twelve days longer. The writer c laim s for his methodthe great simpl icity o f the Operation

,the almo st co nstant preservation

o f the integrity of the iris, and a smaller degree o f pain and distress tothe patients, on account o f the n on-employment Of blepharo stat o r

fixation fo rcep s . NO statistic s o f the metho d are given . Dr.

Martin , chef de c linique to Dr. de Wecker, publishes !“ a statisticalreport o f the o perations performed at the c linique during the secondhalf o f 187 1 . Am ong these were n inety-five fo r cataract, o f whicheighty-six were fo r Spontaneous, five fo r traumatic

,and four for c on

genital cases . The spontaneous and the traumatic cases were all Operated upon after the metho d o f von Graefe, with m odifications asregards the section o f the sc lero tic and as regards the m annero f o pening the capsule . The section is based upon the fo l

lowing rule —The puncture and counter-

p un cture are made in thes c lero tic tissue, a millimetre begond the c ornea l bounda ry, up on a horiz onta l line two mil limetres below the upp er cornea l margin. T he knifeis made to cut its wag o ut a t the level of the sup erior cornea l margin . Inthis way a flap is Obtained, the summ it of which c orresponds exactly tothat o f the c o rnea, while its base , situated two m illimetres lower

,

measures the who le width o f the c ornea at that level,with the addition

‘Annales d’Oculistique,’ 1871 , 11, 202 .

1“ Ib id., 1872 , i, 15 7.

SURGERY . 345

of two millimetres (one on each side) from the sclero tic . If the c o rneao f twelve m illimetres ho riz ontal diameter, the sec tion thus m ade willo f eleven o r eleven and a half m illimetres, while that o f von Graefe

never exceeded ten or ten and a half.a , This enlargement o f the section i s no t necessarily attended by a largeA cision o f the iris . A large c o lob oma may b e avo ided by no t drawingSlit to o much iris prio r to exc ision ; and, when the exc is ion is m ade

,it

is always po ssible, if the iris should tend to lo ck itself into the anglesof the wound, to replace the extrem ities o f the Sphincter by slightmo vements o ver the c ornea with the c onvexity o f the caoutchouc spo on .

It is an important po int in De Wecker’s section that the same rulesuffices fo r all cases and persons , and, unlike Graefe’s, requires no m o dification for very large o r very hard lenses, o r fo r eyes of small cornealdiameter.The division o f the capsule is eflected by a fo rceps resembling iris

forceps, but furnished with a screw to regulate the extent o f separationo f the blades, and with a p o int on each blade to serve as a cystitome .

The fo rceps being introduced c lo sed and horizontal,until it reaches

the inferior margin o f the pupil, is then turned into a vertical p o sition ,

s o that its p o ints perforate the capsule. The blades are then allowedto expand, so that the two po ints incise the capsule ho rizontally

,

at the

level o f the pupillary margin . Still expanded, they are drawn towardsthe section , m aking two parallel inc is ions in a vertical direc tion .

When nearly at the margin o f the lens the blades are c lo sed, the p o intsmaking the second horizontal inc ision ,

and thus cutting o ut a squarepo rtion o f cap sule, c orresponding to rather m o re than the pup illaryarea . AS the blades are c lo sed this p ortion is seized between the fo rceps teeth , and is withdrawn altogether from the eye. The fo rcep scystitom e should on no ac c ount be intro duced until the cut margins o fthe iris are resto red to their proper po sition . After the operation b o theyes are c o vered by c irc ular p ieces o f fine linen ,

o ver which are pads o funglazed wadding, s o p laced as to fill all the space between the o rbitalmargin ,

the bridge Of the no se, and the prominen ce o f the cheeks . Thesepads are retained by a bino cular flannel bandage, which exerts slightpressure o ver the eyes and renders the lids imm o vable. On the eveningo f the o peration a do se o f chlo ral hydrate is adm inistered, and on the

fo llowing m orning, if the pupil is sufliciently dilated and free from c ortex,

no atropine is used. It is only employed when the aqueous is a littleturbid

,when c ortical mas ses remain ,

o r when the iris is threatenedwithinflammatio n . The forego ing Observations are fo llowed by a tablegiving full details o f each c ase and o f the results o btained.

E xtraction without Op ening the cap sule—Dr. Hermann Pagenstecher

if

gives the results Of the m o re recent experiments of his bro ther, Dr .

Al exander Pagenstecher, in this metho d o fOperating, which , during thelast few years, he has applied to 140 cases . Careful o bservation has ledto the c onc lusion that the metho d i s spec ially applicable to c ertaingroup s of cataracts, while o thers are mo re successfully rem o ved byo pening the capsule . T he delicacy o f the latter in certain cases

,and

its intimate union with the zonula, c ontra-indicate the general adoptionit Annales d’Oculistique,’ 1871, 11, 126.


o f the pro ceeding. 0

vantageous when the r

the zonula . In the lattracts

,whether they are

Such arcapsule to the z onula Ofl

'

ers but little resistance. Mo st frequently thec o rtical layers are in a regressive c ondition ,

and the catarac t is c onse

quently somewhat flattened. A third group well suited for the proc eeding c omprises the cataracts which supervene upon irido -cho

ro iditis o r iritis , and which c o exist with c ircul ar po sterio r synechiae.

In such it is,o f c ourse

,necessary to detach the adhesions, and this may

be done with a small blunt silver ho ok . The fourth group c omprisesthe catarac ts that ac company iridodonesis, a state which depends eitherupon regression of the lens or upon diminution in the bul k o f the

vitreous bo dy. The method is especially to be recommended for thecases comprised in the last two c lasses, in which there is a tendencyto inflammation

,and in which it is very important to pro tec t the

iris from débris of cortex and o f capsul e . There is a last and rare

indication in tho se cases in which , prior to laceration o f the capsule, there is escape o f vitreous humo ur. On ac count o f these it isdesirable

,even when intending to open the capsul e, to be always ready

to emp loy the sc o o p .

Besides arriving at these indications, MM . Pagenstecher have muchm odified their o riginal metho d o f operating. They n ow make a linearinc ision upwards , instead o f a flap , and a large iridec tomy. In a few

cases,as so on as this is done, and the eyeball well fixed and turned

downwards,a slight pressure on the lower border o f the c ornea will

cause the lens , enc lo sed in its capsule, to present itself at the inc ision .

Generally,however, it is necessary to employ a Sco op, spec ially c on

structed for the purp o se by Messrs . Weiss and S ons . T he s co op iscarefully carried behind the equator o f the lens, and made to glideo ver the po sterio r cap sule until it reaches the equator on the Oppo siteside . T o fac ilitate th is manoeuvre it is necessary to make s light pressure with the fixation fo rcep s against the lower bo rder Of the lens

,and

thus to push the Oppo s ite margin upwards . After a slight ro tation

, produced by change in the direction o f the sc o op , such that itshandle passes from the centre towards the inner angle of the wound

,

the lens is drawn upwards,the handle o f the sco o p being at the same

time depressed towards the o rbital margin . Thus there is pro duceda sl ight pressure o f the lens against the c ornea, which fo rbids the fo rmerto slip out of the concavity o f the sc o op . Its exit is at the same

time promo ted by a slight pressure on the lower part of the c o rnea bya caoutchouc curette

,which is made to fo llow the advanc ing lens from

below upwards .

Anx sthesia from chloro fo rm,which was always employed when the

flap section was made,is now only prac tised at the espec ial request o f

the patient . E x erience has shown that extraction with the capsul emay be perfo rme as easily through the linear as through the flap in


knife, as if for iridectomy, and withdraws the blade very gently, pressingupon the iris as he do es s o . If pro lap sus should still take place hewaits until the pro truding portion is distended by the resecretion o f

aqueous hum our, and then punc tures it in the direction o f the radialfibres . After this the pro lapsus m ay generally b e readily replaced.

Dr . de Wecker,at the Heidelberg Congress o f referred to

Quaglino’

s results,

and stated that he had himse lf made trial o f

sclero tomy in a somewhat different m anner. He intro duces a Graefe ’scataract knife, by punc ture and c ounter-

punc ture, as if to make a flaptwo millimetres in height, the po int pas s ing through the sc lero tic verynear the c orneal margin . He then divides the s c lero tic for two thirdso f the distance between the punctures , leaving the central third undivided, and retains the knife in the chamber un til the aqueo us hasescaped, when it is slowly withdrawn . In this way he avo ids pro lap seo f the iris . His cases seemed to him to establish the value o f sc lero tomyin reduc ing tension ,

and to show that a c icatrix of fi ltration was the

condition essential to a cure .

Ulcus serpens cornea —Pagenstecher? strongly supp orts Saem isch ’streatment o f creeping ulcer o f the c o rnea . T he treatment previouslyemployed at Wiesbaden c onsisted o f atro pine instillations, with warmpoultices and c ompres sion ,

and it o ften yielded go o d results . But com

p lete o r nearly c omplete lo ss o f vision was suffic iently c omm on to render

a trial o f Saemisch ’s methoddesirable . The results wereI . T he ulcerative pro cess was restrained within its existing limits,

and thus the size o f the eventual leuc oma reduced to a m inimum .

2 . The base o f the ulcer became c lean and les s turbid, and the sur

rounding infiltration who lly disappeared in the c ourse o f a few days .3 . T he pus o r turbid matters in the anterio r chamber were in great

part evacuated, and the abso rption Of the remainder much promo ted.

The risk o f o c c lusion o f the pupil by the o rganization o f false membrane was thus greatly dim inished.

4 . The tendency to iritis rapidly diminishes, and c omplete dilatationo f the pupil is so on produced.

5 . E xisting c iliary neuralgia is c ommonly c ompletely relieved, eitherimmediately o r after the lapse o f a few hours .T he precepts laid down by Saem isch were rigo rously fo llowed in the

making o f the inc is ion . The after- treatment c onsisted in the appli

c ation Of a m o ist c ompress,the in stillation o f atrop ine, the applicatio n

o f a pressure bandage at night, and the frequent reo pening o f theinc is io n . This last, however, was no t c ontinued fo r so long a time as

by Saem isch , but on ly fo r from five to eight days .Corelysis .

—Dr. de W eckeri entirely c ondemns o perations fo rdetaching p o sterio r synechiae, either b y c o relysis o r by Passavant’smethod . He thinks that al l such o perations are usually fo ll owed byanterio r synechiae, the peripheral part o f the iris becom ing united tothe c o rneal wound. The way in which this wound is irritated bypassing ho ok o r fo rceps through it, and the necessary dilatation o f the

it ‘Annales d ’Oculistique, ’ 1872 , i , 87.

.

l Klinische Monatsb latter fur Augenheilkunde.

’

I‘Annales d’Oculistique,’ 1872 , i, 70.

SURGERY . 349

pup il afterwards , c ombine to render such union probable ; and the

anterio r adhesions are as perilous to the eye, if no t m o re so, as

tho se which they supersede . Dr. de Wecker relates the case o f a

gentleman who had a s ingle, very fine band of anterior adhesion in hisleft eye, passing from the inner and lower portion o f the pupillarymargin to the small c ircum scribed scar o f a nearly central c ornea lulcer. Several Ophthalm ic surgeon s attributed frequent attacks o f

peri-orbital pain to the presence o f this adhesion . No thing seemedm ore easy than to detach it , and the attempt was made, witho ut suc cess ,first by Pro f. v . Hasner, then by Prof. Knapp , and, lastly, by Dr. de

Wecker himself. Dr. de Wecker made a small inc is ion at th e margin o f

the c ornea, allowed the aqueo us to escape Slowly,and seized the iris

near the adhesion with forceps . He found, however, that he tore thetissue o f the iris in stead o f breaking the adhesion

,and desisted after

three attempts . -E very operation was fo llowed by union of the iris tothe c o rneal wound, s o that the patient gained three fresh synechiaewithout lo sing the o ld one

,and with out lo sing the pains for which

he had sought advice . Dr . de Wecker rec ommends,in all such cases,

the exc ision o f the portion o f iris that is adherent .Suture of the eyelids

—V erneuil if related to the So c iété de Chirurgiede Paris some cases in which he had pared the edges o f the eyelids andunited them by suture, in o rder to prevent ectrop ion after the extirpation o f an epithelioma o f the lower lid

,and after o ther injuries likely to

be fo llowed by a c ontracted c icatrix,and also fo r the cure Of ectro pio n

actually established by such c ontraction . In one case he maintainedthe un ion o f the margins o f the lids fo r fourteen m onths . The resultsin all his cases were very enc ouraging, and he advo cates the employment o f his method in preference to plastic Operations, which are

usually only imperfectly succes sfulxtBurowI c onfirms Passavant

’

s ac c ount o f the excellent qualities o f theSO-called marine grass (o btained in China from the Sp inning o rgan o f

the silkwo rm) fo r sutures . The threads pro duce no suppuration ,even

if they are suffered to remain for weeks, and are espec ially adapted fo r

plastic o perations about the eyelids . In the same paper he refers tohis use o f threads so aked in c o llodion for twisted sutures . As so on as

the c o llodio n is dry the p ins may be rem o ved. He uses E nglish sewingneedles with bro ad po ints (glo vers ’ needles P) and flo ss s ilk .

Warlomont§ m entions a metho d suggested to him by the elderDesmarres for remo ving suture p ins without dragging upon the c icatrix .

The o perator casts a lo op o f thread o ver the head Of the pin to b e

withdrawn,and steadies the so ft parts by traction upon this lo op with

the left hand,while the pin i s withdrawn by the fo rceps held in the

right .Gunshot wounds—A contribution to Ophthalm ic surgery o f entirelyif ‘Gaz . 187 1 , 473.

1“ Union of the lids h as b een emp loyed in th is c ountry by Mr. Bowman, by the

writer, and by o thers, and the power of hea ling extens ive w ounds by skin graftingnow renders a lo ng p eriod o f o cc lus ion unnecessary

—R . B . C .

I Zur Leh re von der Wundnaht,” Berl in klin . 1871, 155 .

‘Ann . d’Oculistique,

’1871 , i, 73 .

35 0 REPORT ON OPHTHALMIC MEDICINE AND SURGERY .

unprecedented and m o st impo rtantHermann Cohn

,o f Breslau,

wh o ha

cases o f injury to the eyes treated at

and Neunkirchen, during and after

vital parts ; that even the statistical rec o rds o f injuries to the eye are

very imperfect,and that m ilitary Ophthalm ic surgery c an hardly be said

to exist,altho ugh the value o f the o rgans implicated renders this branch

of the art wo rthy o f al l attention . E stimating the superfic ial surfaceo f the b ody at I 5 square feet , and that o f the eyes at 4 square in ches

,

we m ight expect one injury to an eye in every 500 wounds . Demme ,in the Austro -Italian war o f 1859 , saw,

in all, 5 5 c ases o f sho t wound o f

the eyes , am ong which 19 pro duced blindnes s o f b o th . Stromeyer,

amo ng 7 14 invalids from the Schleswig-Ho ls tein campaign , fo und lo sso f eyes in 13 cases

,but has no t rec o rded in how many o f these bo th

were lo s t . William son states that am ong the wounded fro m the lastIndian campaigns there were I 1 cases o f lo ss o f o ne eye, and a singlecase o f lo s s o f b o th . From the Crimean war there were 42 cases o fdestruction o f a single e e, and 2 cases Of lo ss o f bo th . In the Austrianwar o f 1866 Niemets cheksaw 9 and Mo o ren 4 cases o f sho t wo unds o fthe eyes

,and beyond these there are, within Dr. Co hn ’

s knowledge, nostatistic s upon the subjec t. N o c o nc lusion can be drawn from the

number o f so ldiers invalided as blind, since the lists would exc lude all thecases in which injury to the eye had been fo llowed by partial o r c ompleterec overy . E ven in the Franc o -German war it was impo ssible to arriveat the facts with any certainty

,since in a large number o f lists o f

wounded the nature o f the injury was no t stated at all,and in o thers it

i s pro bable that eyes were invo lved in many cases entered as injury tothe fac e, head, or brain . The o nly statistical guidance o f any value isthat furnished by Dr. Fis cherfi who has based a comparative estimateo f the relative frequency o f wo unds o f different parts o f the b ody upon

cases rec o rded from the annals o f m odern warfare. His tableis entitled to weight on ac count Of the large numbers on which it isbased

,and he gives 7 4 as the average percentage o f wounds o f the

brain and head,and 33 as the average percentage o f wounds o f the

face . There are, therefore, 10 7 per cent . o f injuries in which one o r

b o th eyes are liable to be implicated. If we assume that they will beactually imp licated in 10 per cent . o f such injuries

,an estimate that i s

probably no t much sho rt o f the truth, then the wo unded o f

the Franc o -German war would furnish 1000 cases o f eye injury. The

care o f the wounded was divided am ong at least 400 German, French ,and fo reign surgeons, and, espec ially at the beginning o f the war, thec ases o f injury to the eye were scattered among the several m ilitaryho sp itals , along with all o ther cases that would bear remo val

,ins tead

of being sent to the numerous Ophthalmic ho spitals o f Germany . ItContribution to Fischer’ s Kriegs chirurgische E rfahrungen,

’Erlangen, 1872 .

1“ ‘Ueb er Kriegsch irurgie,’ E rlangen, 1868.

REPORT ON OPHTHALMIC MEDICINE AND SURGERit.

Weakness o f external rectiMono cular weakness of accommodationNystagmus

Sympathetic b lepharo -spasm

Pto sisLagophthalmusC icatrix o f lid

Fo reign b ody in l idPterygium

In a case o f wound inflicted by a waggon-wheel passing o ver the eyethere was laceration of the upper lid, fo llowed by defective un ion ; anda case o f bayonet wound o f the o rbit was fo llowed by paralysis of therectus internus , c omp lete pto si s , and pterygium .

The Operations perfo rmed In the 3 1 cases were enuc leation o f the

eyeball in 5 , and in 3 the excis ion o f Splinters o f shell that had penetrated the lids . The fo llowing cases are .among tho se given in detail

Two cases of injury to the brain.

I .—Juschkat, aet. 2 7, was injured in the bra in by a chassep o t ball

befo re Metz,on the 14th August, 1870 , and was struck down stone

blind, but without lo ss o f c ons c iousness . The wound of entrance wassituated an inch and a half abo ve and behind the c oncha o f the rightear, in a line with a pro lo ngation o f the palpebral fissure, and therefo rein the lower and po sterior po rtion of the right parietal bone. Whenthe patient reached Fo rbach, on the 1 7th o fAugust, a po rtion o f brainthe size o f a walnut had escaped from the wound

,and was adhering to

the shirt c o llar . There was no wound o f exit,and the ball was fo und

lying about 2 ” behind and 14" below the wo und o f entrance

,a little to

the right o f the o c c ipital em inence , from which p o sition it was immediately remo ved by Pro f. Fischer. Perception o f light returned the same

even ing, and on the fo llowing day the patient c ould discern the (white ?)c lo thing of the nursing sister wh o had charge o f him . A small quantity o f brain tissue m ixed with pus escaped daily from the wo und

,which

was only gently syringed. The patient had perfec t freedom o fm o vement,

and his taste, smell, and hearing were no rmal . There was no paralys iso f either extremity . Dr. Cohn saw the case fo r the first time on the

2 2nd o f August , eight days after the injury . The eyes were then, asthey had been from the beginning, quite no rmal in external appearance.

In the right eye the pupil measured 2g",and promptly c ontrac ted to

1 5”under lateral illumination or direct lamplight . When lo oking at

the illum inated face o f the Observer it discerned m o vements o f the

hand outwards , upwards and outwards, and downwards and outwards

,

but in no o ther parts o f the field. Co lour perception was lo st, but the

p ower o f distinguishing whether large o bjects were bright o r dark remained

,and, although m o vements o f the hand were seen , the fingers

c ould no t b e c ounted. The Ophthalm o scope showed perfectly c learmedia, the retina nowhere detached. The Optic nerve was muchswo llen , its margins o bscured, its surface exhibiting a radiating striation in the c ourse o f the fibres , the veins distended and winding, thearteries very small , and a number o f fine ves sels were visible

,such as

are never seen in the healthy state. The who le surface o f the disc was

SURGERY . 353

very red, with a greyish tone. Retina healthy. In extreme abduction o r

adduction of the eye there were slight pulsatilemo vements o f the globe .

Tension seem ingly n ormal . Left eye z—Pup il in diameter

, c on

tracting very little at the c lo se appro ach of a flame . NO perception o f

light in any direction . Aspec t o f nerve the same as in the right eye .

The patient Slept and felt well, and answered intelligently all questionsput to him . All functio ns were naturally discharged . Pulse full, 50 .

Dr. Co hn gave a doubtful progno sis , and advised two leeches to b e ap

p lied to the inner angle o f each o rbit . The lo cal c ircum stances prec luded treatment in a dark ro om , and when Dr. Cohn next vis itedForbach

,on the 2 5th o fSeptember, the patient had been sent away . The

no tes in the j ournal were August 2 6, abscess in the neighb ourho odof wound and rem o val o f splinters o f bone after inc ision . Sept . 4 ,sudden acute headache and a rigor. Sept . 14, vision much improved

,

wound healing. Discharged.

”

Dr. Co hn remarks that th is case presents many features Of great interest. It is ano ther illustration o f the well-established fac t that largequantities o f brain substance may be lo st withq ut diso rder of the intelligence . Secondly, it shows that even to tal traumatic amauro sis m ayterm inate in rec o very . Th irdly, that sudden increase o f pres sure on

the brain may pro duce double s tauungsp ap illa , with sudden lo ss o fsight . That the blindness was no t the result o f c oncussion o f the retinaseem s to b e pro ved by the Ophthalmo sco pic exam ination , since suchconcussio n is never attended by visible changes . It must be adm ittedthat in gunsh o t wounds o f the brain we never have symptom s o f purec ompression ,

tho se o f c oncussion and c ontusion being always added.

But in this case everything shows the predom inance o f c ompression ;the slow full pulse on the eighth day, and the c ircum stance that perception o f light was restored to the right eye on the eighth day, immediately after the projectile was remo ved. It is well known that V .

Grafe, in 1866,sought to exp lain the o ccurrence o f stauungspapilla

in intracran ial tum ours , by o bstruction to the flow o f blo o d through thecaverno us sinus . He believed that the passive c ongestion o f the retinalvein thus o ccasioned was multiplied by the c onstriction o f the sclero ticforamen . Sesemann

,however, in 1869 , proved by careful injections that

the retinal vein always c ommunicates with bo th the superior and the

inferior ophthalm ic , and that by c onstant anastom o ses at the innerangle o f the o rbit the blo o d from these veins can always find o utlet bythe fac ial ; so that increased intracranial pressure canno t affec t theo cular c irculation in the manner suppo sed. In the same year it wasshown by Schwalbe that the Space between the two sheaths o f the o pticnerve is c ontinuous with the arachno id space

,and Schm idt

,who re

peated Schwalbe’ s experiments, found that by injecting the arachno id

cavity he c ould distend the space between the nerve sheaths quite up tothe lam ina cribro sa . Hence, he c orrectly inferred that increased intracranial pressure would fo rce the arachno id fluid between the nervesheath s , and pro duce swelling and c ompression at the lam ina cribro sa

,

so as to impede bo th the c irculation Of blo od and the c onduction o f

nervous impressions , and to produce the changes known as stauungs

papilla . Leber to ok the next step , for, in the autopsy of a patient who23


had been the subjec t o f stauungspapilla, he found c onsiderable ting and an oedematous c ondition o f the inner sheath , and o f the

lular tissue separating it from the outer. This tis sue was

hypertrophied, anddiate layer.

” T he case now rec o rded seem s p owerfullySchm idt ’ s view, since in no o ther way co uld the sudden 00

s o great a degree o f stauungSpapilla b e explained. T he

pres sure must have been increased by the presence o f the projectile,the arachno id fluid forced between the nerve-sheaths and againstlamina in such a way that the c ircul ation and the nerve c onduc

were bo th alike arrested.

It may b e urged against this view that, as the Ophthalmo sc o picamination was n o tmade until the eighth day, there is noto the time at which the changes in the disc o c curred. But Dr. Cohnc ontends that it wo uld b e far-fetched to as sume a descending neuriti s,in view o f the instantaneo us blindness , and refers again to the slowpulse as an evidenc e o f pressure . It may als o b e o bjected he says, thata stauungspapilla is no t a suflicient exp lanatio n o f to tal blindness,since many cases have been Observed in which this c ondition has c o

existed with almo st normal vision . He po ints out, however, that therewould be a vast differenc e between the sudden traumatic c ompress ionand even the same degree, ifm ore gradually pro duced. He refers alsoto ano ther po ss ible Objection , namely, that on Schm idt ’s hypo thesisevery case o f c ompression o f the brain would be attendedwith stauungspap illa, which he adm its i s no t the case . He suggests the p o ssibilitythat something may depend upon the part o f the brain from which theincreased pressure pro ceeds, and po ints out the need fo r careful ophthalmOSCOpic exam ination in all perfo rating wounds o f the brain .

present he is aware o f o n ly o ne rec orded case at all sim ilar to the forego ingfi

“ and this was exam ined very superfic ially .

2 . The second case o f brain injury befell Jaschke, eat. 2 3 , who re

c eived a sho t in the head befo re Paris ,'on the 2 o th o f September. He

fell, remained uncons c ious fo r half an hour, and on rec o very found hisleft arm and leg paralysed, and an acute pain in the left side o f

head. He was rem o ved to the G onesse Lazareth , and knew thenwhere he was . He was wearing his helmet when wo unded, and the ballpassed through the right flap o f the helmet and split against the skull .Half passed out through the back part o f the right half o f the helm et,the o ther half lo dged in the brain ,

whence it was rem o ved,three m onth s

later, by Prof. Konig, at Berlin . Dr. Co hn saw the case for the firsttime on the 1 1th o f April . There was then a c ic atrix o ver the rightparietal bone, no t sensitive on pressure, measuring in length andin breadth and depth . The patient had c omplained from the day ofthe

injury o f a dazzling before the right eye, there being no dazzling o f the

left, and bo th being o f n ormal aspect . After reading fo r half an hourthe dazzling of the right eye became exces sive, and was attended bylacrymation . If he abstained from reading he had no inconvenience,It being only produced by exerc ise of the ac commodation . The left

Demme, Speziel le Ch irurg ie, der Schusswunden.

’ Abth . 2 , p . 7.


c onspicuous small o pening, with surrounding tenderness , discharging a

little yellow serum . The vision o f the left eye had been imperfect fromyouth

, and its lids were then spasmodically affected. E nuc leation was

advised, but was necessarily deferred in c on sequence o f o ther calls upon

the surgeons . It was performed o n the 2 4th , by wh ich time impendingpanophthalm itis had m ade further progres s , the fac ial paralysis beingunchanged. The edges o f the lid wounds were at the same time pared,and brought together by sutures . Rec overy to ok p lace favo rably, andon Sept . 2 o th the left eye read Snellen 15 fluently o ver a range o f from

2”to Without a lens]S 3

43 , after neutralizing the myopia by

57 , S No distress o f acc omm o dation after pro longed reading.

T he eyeball was exam ined by Dr. Waldeyer, but it was so much

destroyed by the injury that no thing beyond diffuse purulent infil tration o f the choro id was rec ognisable .

3 , Lego uey, set. 2 2,struck by Splinters o f shell befo re Metz

, on

Aug. 1 7th . After remaining seven hours on the field he Obtained c o ldc ompresses from a French surgeon at the church o f a neighbouringvill age, and after two days was sent he knew no t where. On the 2 4th

o f August he came to Dr. Co hn , by whom , ac c o rding to his own account,he was for the first time carefully exam ined. Imm ediately after theinjury there was , he said, a c onsiderable fluid discharge from the rightear, whether o f blo od he did no t know . There were numerous burnsand abrasions o f the skin o ver the right eyebrow, cheek , and side o f the

no se . The brows were powder-blackened, and at the o uter extremityo f the right eyebrow there was a lacerated wound é” long, discharginga quantity o f greenish pus . T he right lids were c lo sed

,the upper lid

was m o derately swo llen and somewhat hard. On rais ing it the c on

junctiva was seen to be red and much swo llen ,and a scorched brown ish

mass o ccupied the place o f the c o rnea . Lo ss o f vision c omplete. Therewas purulent discharge from the right external audito ry m eatus

,and a

watch c ould no t b e heard with this ear. E nuc leation was perfo rmed

with some difliculty , it being impo ssible to detach the musc les entirelyfrom the torn sc lero tic ; and the eyeball was s o c ompletely dis organisedthat no thing but the s c lero tic was distinguishable . A large number o f

small fragments Of shell were rem o ved from the fo rehead,eyelid, and

cheek , and c o ld c ompresses were applied. G o od reco very fo llowed,and

on O ct. 3rd the repo rt was that the stump had go od m o vement downwards and outwards, but very little in o ther direc tions . Left eye

normal,with n o discomfo rt after c ontinued use .

4 . Sehn ,H . , act . 2 3 , struck by a chassepOt bullet at St. Privat, on Aug .

18th,and seen by Dr. Cohn o n September 13th . The wo und o f entrance

was in the right ala o f the no se, and was brought together by suturestwo hours after it was inflicted. The bullet passed through the nas albo ne, the left superio r maxilla, and the left eye, to the temple, Shattering the upper part o f the o uter margin o f the o rbit

,and escaping 2

”in

front o f the tragus o f the left ear . Many Splinters o f bone had beenrem o ved from the no se and from the tempo ral region . The eyeballwas reduced to a small stump , in which there was n o trace o f c o rnea ,

and which was sensitive to touch . Conjunctiva o f the globe much in

SURGERY . 35 7

flamed. Mo vement downwards lo st, m ovement inwards and outwardslim ited

,m ovement upwards very lim ited . The right eye had M T

1?”

with p .p . fo r NO . 2 at 4 and was painful when used fo r very nearvision . Field n o rmal . Dr. Co hn warned the patient o f the po ssibilityo f sympathetic o phthalmia, and advised him to subm it to enuc leation ifthe field should become c ontracted, o r if the pain felt in accomm odationshould increase. On the 6th o f O ctober he saw the case again, andfound a better state o f things . The p .p . at the field normal

,and all

pain and inflammation had subsided.

5 . G ommenginger, I . , act. 2 2,wounded on Aug. 6th at Spicheren , and

seen by Dr. Cohn onAug. 13th . A bullet had entered at the junction of

the nasal bones with the frontal bone, shattering the cribrifo rm lamellaOf the ethm o id and the zygomatic pro cess o f the right superior maxilla,tearing the right eye o ut o f the o rbit, and issuing on the lower andbackpart Of the cheek, in front of the right ear. The o rifices o f the woundand the cavity o f the o rbit were c o vered by healthy granulation s, withabundant purulent secretion, and pus was also discharged from the no seand m outh . Crep itus c ould b e c learly felt about the zygoma . The

check was much swo llen and very painful on pressure, the swellingsimul ating fac ial paralysis . In the c ourse o f time many s linters o fbone were rem o ved

, and rec o very to ok p lace. On the 2 3rd 0 Sep t . thepatient was discharged, the left eye being o f no rmal aspect and freefrom discomfort .

6 . Max,K .

,set. 2 7 , wounded at Le Bourget on the 2 1 st o f December,

at 9 a .m . ,when in the act o f leaping o ver a ditch . Felt as if his left eye

had been pierced by a needle, then lo st c onsc iousness and fell into theditch

,where he remained two ho urs . At five in the evening fo und him

self a prisoner in the ho sp ital at St. Denis . Had a sensation o f empti

ness in the left orbit,and was to ld that his eye was gone, but do es no t

know whether it had been remo ved by the surgeons . The wound wasinflicted by a round ball from a Rem ington rifle

,and the ball , which he

saw, seemed torn ,as if it had been itself explo sive. A p o rtion o f the

patient ’s go ld Spectacle frame was imbedded in the bullet, and near this apo rtion o f one of the lenses

,fused to an Opalescent c ondition . The bullet

was extracted on the sixth day after the injury, from the left sternomasto id

,ab out 3 ” below the lobe o f the ear. After suffering many pri

vation s he was given o ver to a Prussian o utpo st on the 5th o f Feb .

,and

Dr. Cohn saw him on the 1 1th of May . The margins o f the lids wereun ited towards the outer canthus , s o that the fis sure c o uld n o t b e

opened more than and abo ut 2 ” o f the frontal pro cess o f the m alarbone was wanting. The palpebral c onjunc tiva was a lmo st o f naturalaspect, the o cular somewhat swo llen . N o thing could be seen o f the

eyeball, the place Of which was o c cup ied by a c icatrix o f two branchesmeeting at an angle, and with somewhat swo llen m argins . In the

inner and upper part o f the o rbital cavity a probe detected some hardsubstan ce

,s omewhat but not very sensitive, po ss ibly remains o f an eye

ball . Right eye M = 3 S = I,with

'

difficulty, and under go o d illum ination . Snellen NO . I was read fluently from 2

”to Field of vision

normal . On the I 5th o fMay, in very go od daylight, he read S : I with- 4 . Dr. Cohn instructed him concerning the premonitory signs o f


sympathetic Ophthalmia, which might be exc ited if, as seemed po ssible,some po rtion o f the spectac le were still imbedded in the o rbit . He

was supplied with an artific ial eye, which was but little m ovable .

7 . Steinmetz,F .

, act. 2 6, struck on the right eye and check by shellSplinters befo re Gravelo tte, on the 18th o f August . He was for somehours insensible, and on rec o very found him self in a s lazareth

,where he

disc o vered that he had lo st the sight o f his right eye, which graduallydwindled. During the firs t four weeks after the injury his left eye wasvery sensitive to l ight, and he had sensation s o f dazzling when he at

tempted to read. Dr. Cohn saw him in the fo llowing April, and founds ome badly healed scars about the right eyelids, and the globe shrivelledup to a small kno b, freely m o vable in all direc tions

,very soft

,and no t

sensitive on pressure. The left eye quite normal .8. Rake]

,A.

,act. 30, wounded by a chassepOt bullet befo re Le

Mans, on the 10th o f January. T he ball pierc ed the ro o t o f the no se

and the left eye, and passed out through the o uter margin o f the o rbit .On the 1 0th o f April Dr. Co hn found the left upper lid greatly thickened

,with discharge o f pus from the o rbital cavity . On lifting the lid

with a retractor,some hard substance was felt, but it was impo ssible

to say whether this was the stump o f the eyeball o r a fragment o fbone,S ince the patient was excessively sens itive to pain, and refused to takechlo roform . The right eye was Of no rma l a spect, and the pup il actednaturally

,but the patient c omplained o fc onstan t dazzlingwhen he lo oked

at any Object . He c ould only read NO . 14, and that imperfectly . N o

c onvex lens helped him , b ut only pro duced increased strain . The daz

zling had become much wo rse since he was wounded. An attempt totake the field o f vision roduced lacrymation and blepharo spasm ,

and

was therefo re abandoned)

,but the field seemed to be to tally defec tive on

the inner side. The fundus was normal , except that the cho ro idalep ithelium was alm o st who lly absent

,and this atrophy seemed o f o ld

date,as it extended far fo rward. His vision with this eye was defective

before the war. Dr. Cohn vainly urged him to subm it to an exploration o f the o rbital c avity and to the removal of the stump o r foreignbo dy lo dged there .

U pon the bas is of these eight cases Dr. Co hn discus ses the questionwhether an eyeball lacerated by sho t should generally be enucleated, andif SO , when ? Two grounds are to be urged in favour o f the Operation .

First , the dread o f suppurative cho ro iditis (panOphthalmitis) secondly ,the dread o f sympathetic Ophthalm ia .

With regard to panophthalm itis we kn ow, from the experience o f the

time when c ataracts were remo ved by flap extraction, and when suppuration Of the eyeball o ccurred in a c onsiderable percentage o f thefailures (although by the linear m etho d it has been rendered excessivelyrare) , with how great pain the distension o f the eyeball by pus wasattended. We know, also , that the panophthalmitis la sted three o r

four weeks , and in some cases the pain c ontinued long after the evacu

atio n o f the pus , radiating o ver the who le head,destroying sleep , at

tended by fever, and materially reduc ing strength . E ven in ca ses o f

rap id panophthalm itis, after wounds o f the c il iary region , fo llowed byshrinking o f the eyeball, the c icatric ial contraction has o ften pro duced


a wound of the ciliary body . The same author thinks it doubtfulwhether in all cases o f panophthalm itis the diso rgan isation o fthe c iliarynerves is suffic iently complete to give entire immun ity from the danger.

Whenever, he Observes , he has seen symptom s threatening the sec ondeye fo llow a panOphthalmitiS , he has generally als o found that the latterhad left a painful stump . Although much in the

:histo ry o f sympa

thetic Ophthalm ia is still Obscure, it is, at least, [certain that any kind

Of injury to the c iliary nerves may excite it, and,unfortunately, the

c ommencement o f the m ischief is Often highly insidious . The patientis only brought to the surgeon by subjec tive symptoms at a time whenthe intractable disease has go ne to o far for vis ion to b e preserved.

Mo reo ver, the c ommencement differs much in different cases , beingindicated in some only by very slight c oncentric c ontraction o f the fieldo f vis ion, or by slight fatigue on lo oking at near o bjects

,in o thers by

rap id lo ss o f s ight , constant dazzling and danc ing o f objec ts befo re theeyes

,o r by lacrymation with pho to pho bia . That there i s no available

remedy but enuc leation , and that this Often failsjwhen practised however early after the appearance o f symptom s , i s known to all surgeons ,and it may, therefore, be laid down that the enuc leation o f a sho tblinded eye will preserve its fellow the m ore certain ly the so oner itperformed, and that it should be perfo rmed prio r to the o ccurrence

the smallest lacrymation or c ontrac tion o f the field. In the case

c omm on so ldiers and o thers o f the less educated c las ses , liable to bedistant from skilled ophthalmic surgeons at their own homes , and to b etardy in seeking advice for their ailments

, enuc leation should be perfo rmed as a pro phylactic measure in all perfo rating sho t wounds causingblindness . T he wo o llen seton recommended by v . Gr

'

afe is , at least, o fquestionable trustworthiness for the end in view ; and the section o f

the ciliary nerves,advised by v . Grafe and first practised by Meyer, is

Open to the Objection that it is diflicult to be certain o f dividing all

the nerves by which m ischief may be done, and that , when divided,they may reun ite and resto re the danger o f sympathetic affection . Ithas been urged that fo r the reception o f an artific ial eye a wasted globeIs better than enucleation . On this ground,Him ly advised free divisiono f the eyeball in pan0phthalmitis , and William s the absc ission o f the an

terior halfby passing a catarac t knife through the equator, and c omp leting the section by scisso rs . Apart from the free bleeding from the choro idal vessels that would o ften b e pro duced by such a c ourse, it is evident that them o vements o f such a stump woul d be very imperfect, s incethe recti muscles are inserted in front o f the equator. It canno t bedenied that an artificial eye m o ves better when placed o n the . remains o fthe globe than when on the c onjun ctiva and musc les only but it is alsotrue that the stump is Often irritated by the fo reign bo dy, and thatsympathetic Ophthalmia may b e thus produced.

With regard to the m ethod o f enuc leation Cohn observes that,

a lthough the operation is very easy when dealing with an unopened eyeball o f o rdinary tensio n,

and with a natural c onjunctiva , it becomes verydifficult when the c onjun c tiva is swo llen and the eyeball ruptured o r

very so ft ..

In the former case the po ints o f insertion o f the musc lesare no t easIly found. Dr . Cohn thinks it a matter o f indifference which

SURGE RY . 361

muscle is first divided, or in what order o f succession they are taken .

He o bjects to the method o f the Vienna scho o l,in which the musc le on

the left side is divided at some distance from its insertion into theglo be, and the po rtion still attached is seized by fo rceps and used tom o ve the globe in any desired direction . T o do this dim in ishes themo bility of the resulting stump towards the left. He als o c ondemn sthe use o f Mazeux

’

s ho ok fo rceps , wh ich perm its the es cape o f thec o ntents o f the eyeball

,and injures the preparation ; but rather prefers

spo on -bladed forceps , which will ho ld the eye without injury . He

advises Section o f the optic nerve c lo se to the eyeball, having observed,

when it has been divided far back in cases o f intrao cular tum our, thatthe c onjun ctiva has retracted in healing, and the app lication o f a glasseye has been rendered difficult .Under the head o f Shel l Sp linter in the Ciliary B ody of the Right

Eye,” i s related the c ase o f a m an

,set . 2 6

,who was wo unded before

Paris on the 2 0th o f September, by a fragment o f shell about a cubicline in diameter, which struck the right eye, and pro duced instantaneous blindness , so on fo llowed by swelling. The patien t was treatedby po ultices and atropine instillation fo r three m onths

,at the end o f

which time the left eye began to redden,and objects befo re it appeared to

quiver. The right eye was then rem o ved by Dr. HOring, and when Dr.

Cohn saw the case,on the 2 7th o f February, the sympathetic symptom s

had who lly disappeared, although the patient believed that he c ouldno t see with his left eye quite as c learly as before the injury . The

retina o f the enuc leated eye was who lly detached, the who le globedisorgan ised by inflammation, and the p iece o f shell was embedded inthe c iliary bo dy .

Two cases o f grazed wounds of the eyeball c ontain little wo rthy o fno te, except that in o ne o f them the bullet perfo rmed an iridectomywith great neatness . In bo th the injury was fo llowed by blindness, dueto detachment o f the retina and effusions into the vitreous .Four cases Of wound o f the upper eyelid are rec orded, in one of

which the sho ck seemed to have pro duced a rupture o f the choro idnear the equato rial region . In ano ther the sho ck producedmyopiawith S 5 , in an eye suppo sed to b e previously healthy and emmetro pic .

Five cases o f wo und Of the upper jaw,in which the eyelids and eyes

were implicated, give Dr. Cohn o c casion to remark that he failed in o b

taining prim ary un ion o f eyelid wounds by paring their edges and

inserting sutures seven o r eight days after the wounds were inflicted,and when suppuration was pro ceeding. He rem o ved all the bruisedparts, and o btained exac t appo sition by silk threads . He refers to the

p o ssibility that silver wire m ight have suc ceeded better, but c ounselsearly o peration in such c ases, whenever it is necessary to preserve theoutline and po sition o f the lids . The same cases Show that there is noo ccasion to puncture the anterior chamber in o rder to evacuate effusedblo o d

,which will always be readily absorbed under a compres sive

bandage.

A case Of Contusion of the eyeba ll is related at great length . A b allstruck the outer m argin o f the left o rbit, frac turing the bone and pro

ducing immediate total blindness . The cornea a nd iris retained


their normal aspect, but the nature o f a whitefundus coul d no t be c learly made o ut. After a

turbance Of the o ther eye supervened, and enuc l

to b e due

disappeared afterturned to the nocreased after the enuc leation from 1

15to 5 . The c linical interest o f the

case rests chiefly o n the production o f sympathetic troubles by an injurywhich implicated only the outer side o f the s clero tic , and which neitherdirectly , n or by the subsequent inflammation ,

affected the c iliary body .

A Wound of the zygoma by a rifle-bal l was said by the patientto have been fo llowed by defective vis ion ,

and the c onditions were veryanalogo us to tho se sometimes presented in c ivil practice by “

railwaycases . ” T he injury wa s inflicted on the 18th o f Aug. 1870 and the

patient (twenty-o ne years o ld) was firs t seen by Dr. Co hn on the 6th o f

the fo llowing January . He presented the scar Of the wound o f entrance

in the body o fthe right malar bone, about halfan inch below the externalc anthus, and that o f the wound o f exit an inch and a quarter furtherback , o ver the tempo ral pro cess . The patient said that fo r the firstthree m onths he c o uld scarcely see at al l with the right eye . It hadreceived no direct injury, either internal o r external

, but seemed to protrude a very little m o re than its fellow, and its tensio n seemed somewhat higher. Field of vision n ormal . The Op tic nerve Showed no exca

vation,and some slightly winding veins in the retina were found also

in the o ther eye . There was no manifest difference in c o lour between thedis cs , but perhaps the right wa s a trace less red than the left. The pupilsOf equal size

,the right s omewhat m o re sluggish . T he vision was very

carefully tested on the the 6th o f January b Dr . Cohn ’s assistant, andon the 8th by Dr . Co hn himself, with the foilowing results

Jannary 6.

Right eye.—Snellen 2 5 at the smallest legib le.

W ith 10 , 15 toM a , 8 ea .

Left eye—Snellen from 5”to 9 .

W ith 10, 15 to 4"

51

0" S iii;

January 8.

Right eye—Snellen 2 57 at the smallest legib le.

35 from 2 to

W ith 10, 15 toM s

Left eye - Snellen 15 from 5”to 103

W ith 10 , 15 to 4l S 4 0

."

67 5

After atrop inization o f the right eye he read,on the 1 1th o f January

,

With -i 8, 2 5 Snellen from 3"to 7

”and with 4 , 2 Snellen from 1 5

”

to T he test-types employed on the difl’

erent o c casions were no t thesame, and the susp ic ion o f m alingering was exc ited when it was foundthat the S o f the uninjured left eye varied from 53 to 58between the


Springs instead of in the usual lo ops, and

into tension by the c lo sure o f the blades, s oso on as the hand of the Operator is relaxed. Dr. Heymann* describesa pair o f s o -called needl e-fo rcep s fo r the rem o val o f capsule . T he in

strument is a small pair o f fo rceps, with o rdinary teeth , and one bladei s pro longed beyond the teeth as a cutting po int . It is figured bo th innatural and in double size in the paper. Dr. Warlomont t s eaksfavo rably o f a set o f iridectomy knives, resembling tho se use byWeber

,o f Darm stadt, in his cataract Operation . T he blades are shaped

like the heart o n p laying cards , and four are pro vided, respectively o f

the width o f two , three, fo ur, and five m illimetres . By selecting a

blade o f the width o f the des ired inc ision and by intro duc ing it to thefull extent

,the size o f the internal c o rresponds exactly to that o f the

external wound. Dr . F . M onoyer, o f S trasb ourggthas invented a pairo f new double fixation fo rcep s . They c onsist o f o rdinary fo rceps, carrying a terminal are, each end o f which is fitted with teeth in the o rdinary way, s o that they sei ze the c onjunc tiva at two p o ints at once on

Oppo site s ides o f the c o rnea . The two grasp ing extrem ities are 13m illimetres apart, and the are on which they are placed is o f 13 m illimetres radius . The invento r states that they may b e applied in anydirection

,and that they fix the eye more completely than any instru

ment that acts upon one po int only .

(c) Medicine and Therap eutics .

On the visua l sense in dis eases of the choro id and retina .—Fo rster

read a paper at the Heidelberg Congres s on this subjec t,§ in which hestarted from the well-known fact o f the want o f c orrelation

,in many

diseases o f the choro id and retina , between c ontrac tion o f the field and

impairm ent o f the sense o f vis ion . In certain affectio ns , with a go od

light, the sense is no t materially impaired, while if the light b e lowered, itfails rapidly . In o thers

,the reverse o f this is the ca se. The autho r had

m ade these well-known facts the basis o f som e researches, and believed

that he had done something towards exp lain ing them . He em ployed forthis purp o se a pho tometric apparatus

,c onsisting o f a rectangular b o x,

twelve inches long by eight wide, and six high , having two ho les , bywhich a patient c ould lo o k into the interio r

,and ano ther

, two inchessquare and c o vered with white paper, fo r the admiss ion o f the light o fa candle. This Opening was fitted with two wings o f blackened tin ,

which c ould be c lo sed o r Opened at p leasure by m eans o f a screw,and

a scale and index served to show the size Of the aperture, which co uldb e varied from I to 1500 square m illimetres . T he o bjec ts o f vis ion are

black lines on a white ground, from 1 to 2 centimetres wide by 5 high ,and the test is to determ ine by how small a degree o f light they can beseen . The retinal sensibility

,which the author calls L, will bear an

Inverse pro portion to the S ize of the aperture o f ill um inatio n. Thus,‘Arch iv f. xvn , 1 .

1“ ‘Annales d ’Oculistique,’ 1871, i, 97.I Ib id .

, 187 2 , i, 64 .

Ib id., 1872 , i, 97.

MEDICINE AND THERAPEUTIOS. 365

required fo r the definition o f the test objects ten timesas a norma l eye, would have a retinal sensibility o nly

tenth as great . It fo llows that, if h be the m inimum Of lightssary fo r a normal ey e, and H the m inimum for a diseased eye, thatif

. A no rmal eye distinguishes the Objects when h 2 sq. mm . If,

we take 2 sq . mm . to be I,

‘

and express H by half its actualo f L will always b e a fraction having I for its num e

exed table gives the m ean results Of the exam ination in

third co lumn

Diagno sis .

ap erture.

Optic neuritisAp oplectic retin itisRetinal apoplexyAlbum inurie retinitis (fatty de

generation)Wh ite atrophy Of Optic nerveHem iop ia in c erebral apo p lexyAmb lyop ia from abuse o f alc oh o lo r tob acco

Syph ilitic ch o ro iditisDissem inated ch oro iditisP igmentary retin itisSeparation o f retinaY ellow atrophy of Optic nerve 7 55(from syph ilitic choro iditis)

Norm al eye

There are, therefore, two group s o f diseases . In the first,from

i

No s .

‘ 1 to 7 inclusive the retinal sensibility is very little dim in ished. In

the second, from 8 to 1 2 , it is very c onsiderably dim inished, s o much s othat in many cases the full o pening o f I 5 00 square m illimetres was yetinsuffic ient . The autho r called attention to the fact that the m o rbidpro cesses o f the form er group were such as to affect chiefly the c onduc ting po rtions o f the visual apparatus, such as the fibrous and ganglioniclayers o f the retina

,the optic nerve as far as the brain ,

and perhaps the

brain itself, while tho se Of the latter affec ted chiefly the cho ro id and

the perceptive layer o f the retina . Glauc oma had been om itted fromthe table on ac c ount o f the variableness o f the results . In infiammatory cases, and during the prem on ito ry stage o f cases Of a certain degreeo f acuteness , the visual sense was much dim inished. In chronic casesthe results differed greatly .

Som e o bservations fo llowed on the value o f this exam ination as a

mean s Of diagno sis , e. g . in negativing the suspic ion o f retinal detachment in a case o f turbid vitreous , in wh ich L retained a high value ; andin determ ining the cure o f syphilitic affec tions o f the cho ro id. The

author also used his instrument to disc o ver whether a sco toma was

REPORT ON OPHTHALMIC MEDICINE AND SURGERY.

po sitive,i. e. depending on a cho ro idal lesion implicating

layers of the retina ; or negative, depending on lesion o f

tissues . The fo rmer was rendered m ore c onsp icuous byn ot the latter.

Dr . v . Hippel read a paper on a sim ilar subject,demned the instrument o f Dr. Fo rster as being to o srate determ ination Of

.

S together with L ,

on a sim ilar princ iple, but on a larger seal

amination o f fifty cases, were c o nfirmato rysubsequent discuss ion Dr. A . Weber said tinstrument with advantage .

Circumscribed choroiditis —Dr. A .

mem o ir on circum scrIb ed choro iditi s,under the name o f change in the re

and has , s o to Speak,built up its c lin ical his tory . He describes i

being characterised by the presence , in a single defined part o f

fundus o f the eye, o f changes analogo us to tho se which o c cur in the

disseminated o r areo lar form s o f cho ro iditis . On examination with theOphthalmo scop e there i s seen sometimes a simple tumefaction o r hy

peraemia o f a very limited portion o f the fundus,situated excentrically

on the side beyond the equator,o r mo re centrally, o r even o ver the

region o f the macula ; and sometimes a single spo t o r severa l smallSpo ts o f whitish o r yellowish -white c o lo ur, in the latter case groupeds o c lo sely together as to fo rm a little patch o f agglomerated les ions on

a single part o f the field, while the m o st careful exam ination reveals n ochanges elsewhere. Instead of being whitish o r yellowish-white, thespo t o r spo ts may be of reddish-black o r brown with no tched edges surro unded by a zone either paler o r mo re dark o r there m ay b e a more

o r less white patch in the centre, surrounded by a border various lyc o loured. The diso rder may be divided, in ac c o rdance with the symptom s and the o phthalmo sco ie appearances , into fo ur stages o r perio ds,namely —1 . The perio d 0 hyperaemia and lo ca l c ongestio n. 2 . T he

perio d o f exudation and fatty pro liferation . 3 . T he regressive o r pigmentary period. 4 . T he period of atrophy. These periods are im

portant, because during the two first the malady is within the reach o ftreatment, while during the two last its effects are produced, and are

practically irremediable.

The first subjective symptom experienced by the patient is a veryannoying myodOpsia, the spo t restmg always in the same part o f thefield of vision, and bec oming more marked after long us e o f the eye, or

after expo sure to strong ill um ination . Often,after having c ontinued

for a time, the myodo psia gives p lace to a m o re o r less pronounced hazeo r m ist, which may either o c cupy a single portion of the field

,or may

render all objects indistinct . Two o ther symptom s so on appear, and

pro duce great annoyance . T he first is a pho to phobia,o c curring at

every change from a les s to a greater degree o f ill umination,and o ft

ac companied by an appearance o f rays,pro ceeding from any source of

light, in the directio n o f the impaired part o f the field. The second isit Annales d’Oculistique, ’ 1872 , i, 1 29

—1 56.

368 REPORT ON OPHTHALMIC MEDICINE AND SURGERY.

o f the vitreous body, will be found o f great service . The fourth isapplication to the fo rehead and temp le, on one o r bo th sides , ac cingly as one o r bo th eyes are affected, o f a series Of from three toflying blisters , a res ource that has s carcely ever failed to pro ducem arkedbenefit . The paper terminates with a detailed rec ital o f six cases, whichsupp o rt the statements and c onc lusion s o f the autho r.

Researches on syp hilitic amawrosis and ambh/op ia , by Dr . Galezowskifi“The autho r arrives at the fo llowing conc lus ions :

1 . Syphilitic retinitis and neuri tis m ay exist without any change inthe choro id, and mo st frequently under the fo rm o f an apop lectic andexudative retinitis . Such cases

,however, are o nly exceptional .

2 . Syphilitic retin iti s presents no pathognom onic signs by which itmay be distinguished from o ther fo rm s of retinitis .3 . But if retin itis o r o ptic neuritis b e attended by iritis o r choro iditis

,

with o rwithout flo cculi in the vitreous , it is then undoubtedly syphilitic .

E xperience shows that there is no o ther affection except glauc oma thatwill give rise at once to retinal haemorrhage and to iritis o r cho ro iditis .4 . Disturbances o f co lour vision are c onstant in these two fo rm s o f

eye disease, and espec ially in Optic neuritis .

5 . The mo st efiectual treatment o f these m aladies .i s by iodide o f

po tass ium and perchl oride o f mercury in full do ses .6 . Syphilitic ,

cho ro iditis is the m o st frequent . lesion in cases o f

syphilitic amauro s is o r amblyo pia . The s ign s o f this fo rm o f cho ro iditisare very characteristic , o r even pathognomonic o f syphilis . They are

- I . Disturbance or lo ss Of sight o c curring by attacks o r crises , o ftenseparated by lo ng intervals . 2 . A m ist resembling cobweb flo ating c ons tantly befo re the eye . 3 . Frequent pho topsia . 4 . Pho to pho bia . 5 .

Hemeralopia at an advan ced stage o f the disease. 6 . Preservation o f

central vision fo r a long period, with peripheral c ontractio n o f the field.

7 . Obscured o utline o f o ptic disc . 8. Pigmentary retin itis at a stillm ore advanced stage o f the disease . 9 . Atro phy o f the central vesselsof the disc with preservation o f the ro sy tint due to the cerebral o rnutritive vessels of the o ptic nerve .

7 . Pigmentary retinitis is very Often developed as a consequence o f

syphilitic choro iditis .

8. The pigmentary spo ts arrange themselves along the c ourse o f the

retinal vessels , and also in a generally c ircular fo rm,like the circ les o f

herpes c irc innatus .

9 . T he acquired p igmentary retin itis o f syphilis do es no t difier fromthe c ongenita l fo rm , es pec ially from that which ha s been attributed tothe c onsanguinity o f parents , except in the c ircular fo rm o f the pigmentary spo ts .

10 . Congenital pigmentary retinitis is an hereditary syphilitic affec tion .

I I . Congenital pigmentary retinitis Shoul d b e subjec ted duringinfancy to an io dine o r mercurial treatment . After a certain age it isno longer po ssible to arrest the pro gress o f the malady

,which bec omes

progress ive, and at length destroys the si ht .1 2 . T he children o f syphilitic parents s

ghould be submitted to careful

Ophthalmo sco p ic exam ination from their birth ; and, retin itis once recognised

,it should be treated in the manner indicated abo ve.

‘Arch . Gen. de Jan ., Fev., Mars , 1871 .

RE P O R T

MIDWIFERY AND THE DISEASES OF WOMENAND CHILDREN .

J . J . PHILLIPS, M .D . LOND . ,

ASSISTANT OBSTETRIC PHY SICIAN TO GUY’S HOSPITAL ; ASSISTANT PHY SICIAN T O

THE HOSPITAL FOR SICK CHILDREN ; PHY SICIAN TO THE ROY AL

MATERNITY CHARITY .

I . GY NE COLOGY ,EMBRACING THE PHY SIOLOGY AND PATHOLOGY OF THE

NON -PRE GNANT STAT E .

Anoma lies of S tructure .

DR .L

. NE UGEBAUE R relates Archiv fur Gynako logie, ’ 11, 2 , 187 1)two cases o b served by him o f one-sided haematometra with doubleuterus . The first patient was n ineteen years o ld. She had c ommenced

to menstruate at seventeen ; the flow was pro fuse, and there was

excessive pain in the lower abdom en and pelvis . A swelling, largerthan a fist

, appeared in the hyp ogastrium . After menstruatingregularly a few times there was ameno rrhoea and absence o f pain for

several m onths . Menstruation returned with great suffering. Aswelling extending nearly to the umbilicus was to be felt on the rightS ide o f the abdomen . Having arrived at the diagno sis by the p o sition ,

shape, and relations o f the tumour, and fearing Spontaneo us rup ture,Neugeb auer o

pened the pelvic swellingwith a bistoury by the vagina, anddark brown ,

Odourless , visc ous blo o d, o f the c onsistence o f thin h oney,flowed away .

There was sharp abdom inal pain on the second day, butthe patient impro ved until the fourteenth day, when menstruationreturned, and she died in three days with symptom s o f peritonitis .The second case was that o f a patient o f the sam e age . Menstruationscanty and painful . A swelling on the left side, nearly the s ize o f the

uteru s at the sixth month o f pregnancy . The uterine cavity o f the

right side freely c ommun icated with the vagina . Dr. Chivat Opened

the swelling by the vagina by pushing an o rdInary uterine sound intoit

. Slight fever and abdom inal pain fo r the first three days . On the

thirty-fifth day there suddenly supervened severe pain in the left hip ,then high fever, frequent vomiting, and escape o f blo od-stained muco

24

370 REPORT ON MIDWIEERY , ETC .

pus from the vagina. She died in forty-eight days after theNeugebauer refers to several published cases o f the kind, inage ranged from fourteen to twenty-seven . T he length o f tim

the onset Of the pain s from retention o f tthe c ommencement o f the treatment on a

varied from five weeks to fifteen years . 0

upon, eight rec o vered and seven died.

Two cases o f haematometra in the c lo sed canal o f a bicoare also recorded by Freund and Wheeler ( ‘Bo ston Jo urnal, ’

Steiner also writes Wien . Med. xxi, 2 9 , 187haematometra .

Breisky relates Archiv f. 11, 1,1 87 1 ) a case o f pyometra

and pyoko lpo s lateralis in a girl the subject o f a double uterus . She

had five bro thers and two sisters , all well fo rmed. Often,as a child,

she had suffered from abdominal pains, suppo sed to b e due to worms ;at the age o f sixteen she began to suffer regularly every m onth forthree o r four days from severe pelvic pains , but no menstrual dischargeappeared. There wa s obstinate c onstipation , great anaemia, and dithcult m icturition . When on the po int o f seeking medical advice something burst , to her great relief, and a quantity of pale red, thickish ,foetid fluid escaped. The diflicult m icturition returned ; Breisky punctured a swelling in the vagina, and an abundant quantity of pus

was discharged. The cavity Of the abscess was carefully washed o ut.

Subsequent dilatation enabled the c ondition o f parts to b e a scertained,

and Breisky divided the vaginal septum and part of the uterineseptum . The patient made a go od reco very , and the right half o f theuterus (the seat o f the abscess) afterwards underwent such c ontrac tionthat its cavity appeared shorter than that o f the left . As ascertainedby the sound the right measured 4 cm . and the left 6 cm .

Two cases o f absence of the vagina are rec orded b Branco . In the

first case, set. 2 5 , the vulva was no rmal no trace o fya vagina existed

,

but it was determ ined to attempt the fo rmation o f one . The tissuewhich had to b e dissected was a little m ore resisting than o rdinaryc ellular tissue . The uterus was reached and punc tured on ac c ount o fthe menstrual retention . After a severe attack o f peritonitis thepatient rec o vered. A sec ond puncture was neces sary in fifteen m onths,and when the patient was last seen the vagina was much c ontracted.

In the second case, set . 2 0,the treatment was m o re suc cessful, the

vagina being kept dilated. Branco contro verts the Op inion o f Scanzonithat c omplete absence o f the vagina is no t met with except in c onjunction with absence o r a rudimentary state o f the uterus , and nearlyalways with defo rm ity o f the vulva . He shows that the developm ent o f the genital o rgans takes place in three z ones

,indepen

dent the one o f the !o ther ; the external parts in the external layer o f

the blasto derm,the internal o rgans in the blastema interpo sed between

the two layers o f the blastoderm , but the vagina i s fo rmed in the fo ldo f divis ion which arises in the prim itive c lo aca . He disappro ves o f

o perative interference except fo r menstrual retention ; and the operation should no t b e perfo rmed at a menstrual period. (

‘Journ . de

Bruxe lles, ’ Nov.

REPORT ON MIDWIFERY, E TC.

Menstruation.

E arly app earance of menstruation—Mr. Ashton states Lancet,’

March , 187 1 ) that he has a patient , act. 7 , who had a slight red discharge from the vagina two weeks after birth . This recurred sometimes once a m onth , at o ther times after an interva l o f two or threem o nths, till the child was fo ur years Old . S ince then the discharge hasbeen “ regular, ” and suffic ient in quantity to so il one diaper. The

child’s m o ther first menstruated when nine years o ld, and the mo ther’ saunt at the age Of seven .

Flugel rec ords Centr . f. Med. Feb . 1872 ) a case in wh ichmenstruation c ommenced at eighteen m onths , and c ontinued with fairregularity until death at the age o f five and a half years . The child

was five feet highDisorders of Menstruation

‘

Dr. Ro ckwell repo rts Amer. Journal o f Obstetrics ,’ May, 1872 )

eight cases o f amenorrhoea—one o f the cas es was o f four years’ durationand ano ther o f two years and a half—in all o f which menstruationreappeared after the use o f faradization o r gal vanism. Generalfaradization i s indicated in tho se c ondition s o f debility where a generaland powerful tonic influence is called for. Faradization lo calisedexternally is but slightly efficac ious . The electro -muscular c ontraetility o f the abdom inal muscles is so great that a current o f but littletension can be used, and neither by reflex nor direct action can the

great sympathetic in this way b e decidedly influenced. Faradizationlo calised internally, however, is a very effective method Of treatment,and by it the uterus can be m o re thoroughly and powerfully influencedthan in any o ther way. S ometimes central galvanization or peripheralgalvanization ,

either external o r internal , is more effectual .Dr. Wade, in a c linical lecture (‘Brit . Med. J July,

c oncludes that ( 1) chloro sis o c curring in young women who have men

struated at al l is c omm only the result o fthe l o ss o f blo od by the menstrualdischarge (2 ) when amenorrhoea o c curs in these cases it is a c onsequence,and no t a cause, o f the anaem ia and (3) b o th primary and subsequentm enstruations pro duce on the system the same efl

'

ects that wo uld beproduced by any o ther haem orrhage o f equal amount . Gaillard Thomas(‘Diseases o f Women ,

’1 872 ) believes that chloro sis is a neuro sis o f

the ganglionic system of nerves . Diso rdering the c ontro l which thissystem exerts o ver the functions o f o rganic life, it produces, as symptom s Of its existence, impo verishment o f the blo o d, c onstipation,

dyspepsia, palp itation ,and menstrual derangements and irregularities .

Many observers have thought, from its o rdinary period o f invasionbeing the time o f puberty, when the do rmant function s o f the o variesare aroused, that it is dependent on some derangement in o vulation and

m enstruation but it is m ore probable that torpiditv o f the uterus ando y arIeS i s , like the peculiar blo od state which is s o Characteristic o f the

d1s order, merely a symptom o f functional disease in the sympatheticsystem o f nerves . Several French patho logists have o f late yearsadvanced the VIew that chlo ro sis differs from anaemia mainly in this

DECIDUA MENSTRUALIS . 373

that the latter i s merely a blo o d state, wh ile the fo rmer is a disease o f

the nervo us system ,which may o r may no t produce the latter. Rac i

borsky also regards chloro sis as due to dis order affecting the ganglionicnervous system .

Virchow has lately written on the relation between chloro sis andvascular abno rmalities U eber die Chlo ro se,’ &c . , Berl in,

A case of “ supplementary ” haem o rrhage from the breasts in a girlwho had no t mens truated is rec o rded by Meynet . The patient wasseventeen years o f age on adm ission to HOtel Dieu

,and stated that fo r

eight m onths she had each m onth suffered from a rather free dischargeo f blo od, lasting two o r three days, from a crack in the nipple, sometimes on one side, S ometim es on the o ther. T he haem o rrhage waspreceded by pain and swelling o f the breasts . Although she had nevermenstruated, she snflered, at the time o f the mo nthly dis chargefrom the breasts, from abdom inal pain and a sensation Of fulness .The patient was under observation fo r three m onths

,and the above

mentioned facts were observed each m onth . In two m onths after she

left the ho spital , where she had been treated by tonic s , menstruationappeared naturally, and no thing abnormal was subsequently no ticed inthe breasts Lyo n March

,

A case o f s o -called vicario us menstruation by haem o rrhage from the

no se is related by Obermeier. The epistaxis ceased during pregnancyVirchow’s Archiv

,

’

Dysmenorrhcea .

Decidua Menstrua lis .—A case o f the inflammato ry form o f dys

meno rrhoea . Dr. A . So l owiefl’

,o f Kasan

,relates Archiv f.

ii,I,1871 ) a case o f the abo ve . T he patient was twenty-one years o f

age, and had been ill three years'

. Menstruation began at eleven , was

always irregular, and accompanied with great pains . Married at

sixteen and a half. Pregnant in four m onths . Labour at full time .

Left o ff suckling at eight m onths . The first menstruation after weaning was painless , but the fo llowing period did no t appear at the propertime, and the patient suffered from a Sensation of weight in the lowerpart o f the abdomen and espec ially in standing up and in walking.

The menses appeared in a fo rtnight, attended with strong pains , and on

the third day a mas s , the exact shape o f the uterine cavity,was passed .

These pain s did no t disappear, but increased in severity at eachmen strual perio d. The vagina was red and s o sensitive that it couldno t even b e touched . A sim ilar mas s appeared at each perio d.

Menstruation was always delayed a week or two . Patient bedridden .

Great irritability ; neuralgia in different parts o f the bo dy ; hyperaesthesia o f the skin , especially o f the abdomen diso rders o f digestionintestinal pains . The sens itiveness o f the vagina dim inished, so thatthe intro duc tion o f a very small speculum was

,with great trouble ,

po s sible . The uterus was m o re c ongested than natural,and somewhat

enlarged ; the m o st tender part was the vaginal ro o f, to uching whichcalled fo rth a suc cession o f reflex hysterical symptoms . Vario us kindso f treatment were employed

,but the mo st useful was the injection of

374 REPORT ON MIDWIEERY , ETC.

perchlo ride o f iron . This was used at first every second day, and

afterwards daily . It dim inished the lo c al pain , but frequent injectioncaused sleeplessness and palpitation . Fo r eight m onths the injectionswere continued, generally every fourth o r fifth day. The membranec eased to b e expelled, and menstruation became regular. After describing the naked-eye appearance o f the membrane, So lowieff says thata transverse section under the m icro scope shows three layers , which ,pro ceeding from without inwards, may b e called the fibrinous , the

glandular, and the granulation layers . The fibrinous layer c onsists o ffibrin

,am ong the fibres Of which lie red

,and o c casionally white, blo o d

c o rpusc les . In the glandular layer the glands are o f the usual Size, andc ontain cylindrical e

pithelium with round cells

,the c ells being o f

various sizes , and the argest c ontaining s om etimes three nuclei . The

granulation tissue c ons ists o f round and lengthy pro toplasma -cells,with

a large nuc leus . The cells lie in a delicate, somewhat fibrous, intermediate substance. The vessels form lo ops on the inner surface .

The innermo st surface is irregularly c o vered with mucus . NO epithe

lium is to be seen . These three layers , however, pass s o gradually theone into the o ther that a sharp line o f demarcation canno t be drawn ,

and a division can only be made acco rding to the predom inance o f one

or o ther element .Membranous dysmen orrhoea is also elaborately described by Michaud

and Lagrave Arch . Gener. de i,Dr. Barnes writes on the essentia l cause of dysmenorrhoea, as illus

trated by cases o f m enstrual retention . He seeks, by c omparison o f

different cases o f dysmeno rrhoea,to disc o ver a c omm on essential

c ause . Having adverted to the evidence accumulated in pro o f thatcases of neuralgic and constitutional dysmeno rrhoea are being graduallytranspo sed under c lo ser c linical analogies to the c lass of Obstructivedysmenorrhoea, the autho r states the pro po sition that the essential c onditio n in a large pro po rtion o f cases is really retention o f

m enstrual fluid. He illustrates this by several cases o f c ongenital andacquired steno sis and atresia o f the genital canal . Dysmenorrhoea isincomplete retention . Obstet.Dr. Priestley read a paper before theMedical and Chirurgical So c iety

(N ov. 187 1) on intermenstrua l dysmenorrhoea . In all the casesdetailed severe pain was experienced by the patients m idway in the

menstrual interval . It generally came about fourteen days after a

c atamenial period, and after lasting a variable number o f days ceasedbefo re the supervention o f the next perio d

, o r o ccasionally ran into thefo llowing m onthly period and was relieved by it. There c ould belittle doubt that the pain was due to perturbations in the func tion o f

spontaneous ovulation habitually go ing on in the o vary . Probablypreparation for an appro aching perio d began in the o vary ten o r fo ur

teen days before the o c currence o f the m onthly uterine discharge , andif the initial steps in the pro cess o f o vulation were Oppo sed by certainpatho logical c onditions pain would ensue.

De Cristo fo ris relates three cases o f flexion with dysmenorrhoea and

sterility, all o f which were cured by mechanically redressing the uterus ,pregnancy supervening in each case. He says that in such cases it

376 REPORT ON MIDWIFERY , E TC .

tissues and of the new fo rmation hanging to it . Other parts showbetter preserved, but also rough wart-like elevations , knobs o r p o lypo usexcrescences . The diffuse infiltration m ay penetrate all the tis suestrata , so that the new growth presents the aspect o f an enorm ous

uterus , retain ing its o rdinary shape . The two kinds , distinct and

diffuse, are at times blended. It is rem arkable that apparently soundp arenchyma is at times dissem inated thro ugh the diseased tissue, recognised as fo ci by the m icro scope . The first o rigin o f the degenerationi s c ommonly sought in the mucous membrane, pro ceeding from whencethe submucous and muscular tissue i s invaded. The c o lour o f the

tumour is generally greyish-white, even white, but sometimes reddishgrey . The c onsistency differs . The tumour is s o ft, s o that it breaksdown under the fingers or the po lypus fo rceps, like brain sub stance o r

wet m ortar. It m ay, however, be denser, like a so ft o r even a hardmyoma . The round-cell sarcoma and the medullary fo rm s are m o stfrequently found. The cells are either o f medium size o r small . The

basis substance i s homogeneous, finely s triped, no t seldom delicatelynetted, as in glio sarc oma . The Spindle-cell sarcomas appear to be

m o re rare. Combinations o f round and spindle cells are m o re c ommo n .

When a large propo rtion o f fibrous c onnective tissue enters into thec onstitution o f the tumour it acquires a firmer consistency . T he pro

p o rtion o f fibrous c onnective tissue may b e so great that we are

c ompelled to adm it a transition form ,a fibro and myo

-sarc oma . In

some c ases the fibrous tissue is s o preponderant that only very carefulinvestigation can detect the significant different tissue . Such mixedtumours may have existed from the beginning, but a sarcomatouspro liferation may spread through a groundwo rk o f fibrO-myoma .

Virchow speaks o f pro liferation pro cess o f myxomatous character intothe rich and extensive interstitial tissue of many myxomas . Numerousvessels penetrate the structure o f m any sarcomas . The concurrence Of

carc inom atous and sarcomatous tum ours is less c ommon than the

transition fo rm s and m ixed fo rm s o f myofibromas and sarcomas .Secondary dep o s its o f the sarc om a in distant o rgans are Seldom men

tioned, as in the lungs,the parietal pericardium ; they only appear

after long duration o f the disease. Depo sits in neighbouringo rgans are somewhat m o re frequent

,as extension of the degeneration

to the vagina, to the rectum,with c onsecutive stricture and ileus .

Depo sits in the lumbar and retro -peritoneal glands o c cur. The etio logyis Obscure . It has been met with in puberty and in the c limactericperiod, in virgins and in women who have b orne children . The

previo us health has been described as excellent . But in a smallnumber o f cases distress po inting to antecedent disease o f the sexualo rgans has been c omp lained o f, as dysmeno rrhoea

,irregular, frequent,

pro trac ted menstruation, discharges , rather watery than sanguineo us ,leuc orrh oea, abortions , sterility, and sometimes hysterical and nervo ushabits . One o f the earliest signs o f the existence o f the tumour ism eno rrhagia . This is very Often attended by irregular o r persistenthemo rrhages . Ofl

'

ensive mucous discharge was in one case the first symptom

,being fo llowed by bleeding. Peculiar haemorrhages and an o ffens ive

puriform o r flesh -water like discharge are rarely absent . These dis

UTERINE TUMOURS, E TC. 377

charges may resemble tho se of carc inoma of the cervix,but the Odour

is generally less penetrating . At a later stage the discharges c ontainnumerous small and larger shreds o f the tum our. Sometimes a p o ly.

p o id projecting po rtion is cast Off, o r falls into purulent degeneratio n,giving rise to an into lerable stench . T o these discharges are sometimesadded as early symptoms a sensation of pressure, Of bearing-down painin the sacrum ,

in the pelvis , pressure on the rectum ,dysuria . But

Hegar do es no t agree with Gusserow in adm itting that pain is c onstantand early. Mo stly the pains po ssess a labour-like Character and po intto real c ontractions . Besides these princ ipal symptom s there are

numerous SO -called c onsensual symptoms,such as attend the m o st

different diseases o f the sexual organs, espec ially disorders o f digestion ,

cardialgia, &c .,nervous symptoms , nutrition suffers from dysuria

hydronephro sis may fo llow . T he c onstant issue is death,which either

ensues from exhaustion through the pro tracted discharges, throughpyaemia , o r the c onsecutive diseases . O bjective symptom s in the livingvary according to the anatom ical relations o f the new growth . Throughthe abdom inal walls we may feel tum ours o f varying size, knobby, o verlapping, o r distinct, between which the bo dy o f the uterus may be

made out o r lo st in the imbedded tum ours . If,in the case o f an intra

uterine tumour,rap id degeneration do es no t ensue, the cervix gradually

dilates , its wall so ftens , its lips disappear, the o s uteri Opens, and thetumour is driven through, perhaps into the vagina, simulating a fibrouspo lypus , when it becomes gangreno us, suppurative, and is cast o ff inlarger o r smaller p ieces . The sound generally indic ates an enlargedc avity of the body o f the uterus , and strikes upon rough , irregularplaces . The m obility of the uterus is Often retained for a long time. Ata late stage peritonitis, pro ceeding from the extension o f the disease tothe neighbouring o rgans , may fix the o rgan . The diagno sis is generally c lear

,but the m icro sco pe alone makes it certain . It is easy to

get small p o rtion s o f the tum our. S imple hyperplastic growths are

distinguished by their fibrous connective tissue muscular substan ce,vessels , fo llic les , glands . The duration o f the disease is variable,

from five months to six years . But it lasts longer than carc inoma o f

the cervix. The treatment is simple. If the cervix is no t dilated,it

must be dilated, s o that the finger may reach the basis o f the tumourand permit its remo val by scissors or po lypus fo rcep s . Generally ho okstear o ut and will not ho ld. After the o peration, Hegar has intro ducedpo tassa fusa ; a c opious discharge fo llowed, bringing away shreds Of thetum our. Hegar c oncludes by relating eight cases . [From Brit . andFo reign Med.

-Chir. Review,’ July,Winckel also describes two cases o f sarcoma o f the uterus and the

m icro scopical appearances o f the growths Arch . f. iii, 2 ,See also Bab l-Riickhard Beit . zu Berlin , p . 76,Dr. No eggerath rem o ved from the p o sterior surface o f the uterus by

a curette a small growth the size Of a pea, in which were felt hardpo ints , sandy to the touch . The growth was an adeno id tumour, and

an example o f the growths called by Virchow p sammomata . Amer.

Journ . o f Feb . 1872 .

An inverted uterus with an intramural fibro idwas removed by ecrase.

378 REPORT ON MIDWIPERY, E TC .

ment by Dr. T . Hay. Befo re the o peration it was evident that an inverted uterus existed, but its large size c ould no t be accounted for. The

stump o f the inverted uterus o c cupied a lmo st as high a p o sition withinthe abdomen as the o rgan do es in its natural po sition . The patient wasthirty-two years o ld, the m o ther o f one child, Six years o f age . The

entire mass rem oved weighed one pound. The fie id was fo und im

bedded in the parietes o f the uterus, and from pressure anddistension thetissues c o vering it were very much attenuated, and round the base s o thinand firm ly adherent as to be separable o nly with great diflicul ty.

Amer. Rep o rter,’ Dec .

Dr. Valette relates (‘Lyon April , 1 87 1) a case o f inversiono f the uterus, in which the uterus was extirpated by the caustic ligature. T he patient was forty-two years o f age, the mo ther o f sevenchildren ,

the youngest child being four years o f age. Two yearsprevious ly She began to suffer from severe metrorrhagia, and eightm onths befo re adm ission She was seized with severe pain l ike that o f

labour, which ceased immediately on the appearance o f a firm tumourat the vulva . There was much anxiety o f c ountenance, c onstant painc onfining her to her b ed fo r seven m onths, and allowing her no rest atnight, great anaem ia, and fo r two m onths inc ontinence o f urine. The

vaginal inlet was o bstructed by a large tumour , compo sed o f two parts .T he lower po rtion was as large as a fist

,firm

,n o t tender

,o f a pale ro se

co lour. The second portio n, situated abo ve the preceding, from whichit was separated by a pedic le, three centimetres in diameter, was smo o th ,and redder than the lower portion . The first was a fibrous po lyp, thesecond the inverted body o f the uterus . Valette determ ined to extir

pate the who le o f the tum our,which was done by the instrument he

describes . There was no haemo rrhage, and rec o very was uninterrupted.

The pulse after the o peration never exceeded 88, n o r the temperature38 5

°C . He po ints out the disadvantages o f (1) simple exc is ion with

a cutting instrument, (2 ) ecrasement,and (3) ligature ; and c on

s iders the caustic ligature, many years ago advo cated by Coutaret,as

by far the safest pro cedure .

Gaillard Thomas writes on the enuc leation of sessile uterine fi broids .

The m ethods o f dealing with these growths he enumerates under threeheads—( I ) the setting up within their tissue a pro cess o f s loughing ;(2 ) the impairm ent o f their nutrition by direc t and deep incisions, and(3 ) their removal by enuc leation . The first metho d presents greatdangers from septicaemia ; the sec ond is attended with the danger Ofhaemorrhage , and is withal very uncertain as to results ; so that thethird, although by no means free from danger, presents itself as a valuable resource in a m o st intractable affection , fo r the reason that it isthe m o st efl

'

ec tual and least hazardous o f the pro cedures now at our

diSpo sal . The day may come when electro lysis will take the place Of

enuc leation . E nucleation Should n o t be reso rted to unles s the state o f

the patient ab s o lutely requires it o n acc o unt o f pro longed and dan

gerons haem o rrhages . Full and c omplete Open ing o f the OS internumshould be effected by tents

,and the attachments o f the tum our sho uld

b e ascertained as accurately as po ssible. Thomas finds a pliable whal ebone rod very useful fo r the latter purpo se. Theuterus must then be

RE PORT ON MIDWIFERY , E TC.

the uterus oppo site to where it is attached. A steel wire is sometimesmuch m ore effic ient fo r their remo val than a soft iron wire. T he steelwire can b e c ompressed to get it thro ugh the o s uteri, and it thenexpands by its own elastic ity, and is easily slipped o ver the tum our.

An excellent des cription o f the various kinds o f uterine po lyp i is givenby Duncan (‘E din . Med. July, 3

Guénio t, in a treatise on the absorption o f fibro ids o f the uterus,

states that the disappearance Of such tum ours by abso rption , althoughstill denied, ought now to be accepted as an ascertained truth . Theysometimes disappear even rapidly, a few m o nths sufficing fo r the dis

appearance o f very large uterine myomas . Ac c ording to the as oer

tained facts the absorp tion takes p lac e during the period Of sexualactivity, but the puerperal state only exceptionally seem s to exerc isean evident influence o ver it . U terine myomas m ay also disappearwithout o peration by two o ther pro cesses

,viz . spontaneous expul

sion and gangrenous destruc tion o r suppuration but their dis

appearance by abso rption is the o nly metho d exem pt from danger and

always fo llowed by rec o very . Fatty degeneration ,judging from

analo gy, appears neces sary as a preliminary to their absorption ,and

Guénio t thinks that such substances as favo i1r this change sho uldbe employed, such as arsenic , pho spho rus, and lead. Arch . Génér. de

April ,A fibro id of the uterus

,weighing nine ounces , is reported by Dr.

Hardie, in the practice o f Dr. Duncan,to have become spontaneously

separated. It lay in the vagina in a putrified state, and set up chronicsepticaem ia , from which the patient quickly rec o vered after the remo valo f the tum our . Med. Times and July,Dr. Brunton Obstet . xiii) believes that in a case o f fibro id

enlargement of the uterus ergo t o f rye prom o ted the disappearance Of

the growth by maintaining uterine c ontraction , promo ting its abs orptionby m echanical pressure. Hildebrandt (‘Berl . Klin . 187 2 )expresses a similar Opinion o f the ac tion o f ergo tin injected sub cu

taneo usly, the nutrition o f the fibro id being interfered with by theincreased compression . T he medical treatment o f fibro id tumours o fthe uterus beyond surgical interference i s the subject o f remarks byvarious o bservers Brit . Med. J April ,Dr . McClinto ck described to the Dublin Obstetrical So c iety inFebruary, 1872 , a metho d o f rem o ving uterine po lypi by means o f alo op o f twisted, silken, fishing line attached to a G o o ch ’s doublec annula . The ligature having been careful ly adjusted, the instrumentis slipped up the tumo ur and the ligature drawn tight . The cannulaebeing held in po sition ,

the ligature is drawn firmly to and fro , and the

neck o f the tum our i s s o on cut through . He believes that hemp -saw

is adequate to cut through the structure o f any vaginal o r uterinetumour requiring extirpation ,

and that it i s m ore easily and with m o re

certainty applied round the neck o f such a tum our than a wireligature is .Mr. Bryant details a case o f c omp lete extirpation Of the uterus and

o varies for fibre -cystic disease . T he bro ad ligaments were securelyseparated, and the uterus at its neck was ligatured in halves . A

UTERINE TUMOURS, m o. 381

strong c lamp was put on,which sloughed o ff on the fo urteenth day.

The tumour weighed eight and a half pounds . Reco very was uninterrupted. Obstet .Dr. W. F . Atlee relates a case o f fibro cystic disease o f the uterus

,

believed to be o varian, which was subjected to o peration . The massweighed five p ounds . The patient rec o vered . The uterine cavity wasno t lengthened. Amer. Journ . o fMed. July

,

Dr. Lloyd Roberts rec ords the suc cessful remo val o f a fibro cystictumour o f the uterus , suppo sed befo re operation to be an o variantumour. N0 increase in length o f uterus . Tumour weighed twentythree pounds . Obstet .Gayet quo tes a case o f cystic myoma o f the uterus m istaken fo r an

o varian tumour,in which

,befo re the operation, the tumour was tapped

and several quarts o f a transparent yellowish fluid were withdrawn .

(‘Lyon March,Mr. Spencer Wells

,in some remarks on the differential diagno sis o f

uterine from o varian tumo urs (‘Med.-Chir . liv) states that

there are m ore than a hundred cases on record where the abdomen hasbeen opened with the o bjec t o f rem o ving an ovarian tumour, but theo perator discovered that the tumour was n o t o varian

,but uterine.

Visible enlargement o f the abdomen is mo re o ften genera l 'in cases o fo varian tumours, andp artia l in uterine tumours, being confined to thelower part o f the abdomen until a very large size has been attained.

The depression o f the umbilicus is dim inished, o r the umbilicus maybec ome prominent in large o varian cysts . This is rarely seen inuterine tumo urs unless fluid is also present in the peritoneal cavity .

E nlargement o f the superfic ial veins o f the abdom inal wall is m o re

c ommon in uterine than in o varian tum ours o f m oderate size. Nearlyall uterine tumo urs, though visibly m o ving above, seem to be fixedbelow in the hypogastric region . Very great proportionate increase o f

the space from the pubes to the umbilicus is m o re c omm on in uterinethan in o varian tumours . As a rule, the fluid

. po rtion preponderatesin an o varian tum our, the so lid in a uterine tumour. The m obility o fo varian tumours is generally greater from below upwards than that o futerine tumours . Vascular murmurs are c omm on in uterine

,very

rare in o varian ,tum ours . The diagno sis is much aided by exam ining

by the vagina and the rectum .

Fo r remarks on the differential diagno sis o f fibro cystic disease o f the

uterus and o varian tumours see also Lee (‘New Y o rk Jo urnal, ’ N o v.

Beatty Brit. Med. No v. and discussion at

Obstetrical So c iety Obst . March ,Dr. Snow Beck furnishes a careful m icro sc opical account o f the

s tructure of the uterus (‘Obstet . It is made up o f

fus ifo rm fibre-cells , which fo rm striae, bands , o r layers, having in the

unimpregnated o rgan a small am ount o f amorphous transparent tissuesurrounding each fibre- cell , and o f o val o r round c orpusc les and

m inute m o lecules or granules imbedded in a c onsiderable amount o ftran sparent amo rphous tissue, and c onstituting what he terms the softtis sue o f the uterus . The internal surface is compo sed entirely o f so fttissue

,and this has the utricular glands imbedded in it . The so ft

382 REPORT ON nirnwrrnux, ETC.

tissue also penetrates into the walls o f the uterus, and is met with indecreasing amount towards the outer surface. It Wl ll thus b e seenthat Dr. Beck do es no t admit the existence o f a defined mucous membrane on the inner surface .

Uterine Cancer.

Sp iegelberg writes Arch . f. iii, a , 1872 ) on the diagno siso f the first stage o f cancer o f the neck o f the womb . He says that thehardness and unyielding character o f mal ignant depo sit, as c ompared

with the firm and rough c onsistence o f benign induration, is wellknown , but he relies on two o ther signs which may b e briefly de

scribed as fo l lows —In malignant degeneration the o verlying muc ousm embrane is always imm o vable, firmly c onnected with the underlyingtis sue, which is no t the case in simple hyperplastic induration ; andwhile the latter, under the pressure o f a sponge-tent in the cervix,dilates regularly and becomes lo o ser, softer, and thinner, the cancerousinfiltration continues unaltered, firm ,

and hard, and do es no t bec omestretched. Sp iegelberg is no t in favour o f operative interference whenthe disease is far advanced.

Dr. Madge,after a careful exam inatio n, repo rted that a spec imen

exhibited by Dr. Pro thero e Sm ith before the Obstetrical So c iety wasone o f epithelial cancer o f the lin ing membrane o f the body o f the

uterus , which destroyed po rtions o f the uterine substance w ithoutaffecting the cervix . The bulging masses no ticed on the inner surfacewere made up o f a variety o f elements , m inutes granules , o il -globules ,epithelial cells, and o ther cells o f an irregular and nondescript character,with a little earthy matter, all c ontained in a stroma o f connectivetissue. Obstet .Dr. Henry Bennett reco rds a case

,very obscure as regards the dia

gno sis during life, o f malignant disease o f the body o f the uterus . T he

patient was fifty years o f age, had ceased to menstruate for two years,and a uterine tum our was casually disco vered by the hand on the hypogastric region . The uterus was enlarged to about the size o f four

m onths’ pregnancy,perfec tly free from adhesions

,movable in everydirec

tion ; there was no vaginal discharge . The sound passed four inches .In fo rty-eight hours after this she was seized with peritonitis and died.

A large encephalo id cancero us tumour was found in the uterine cavity.

Brit . Med. J Sept .Arpem, in L

’

Impartiale’o f Florence, publishes a case wh ich , if

the diagno sis be correct, shows the marked influence of gastric juiceon uterine cancer . The patient was fifty-eight years o ld, with malignant disease o f the rectum and o f the neck o f the uterus . Afterstopp ing the haemorrhage by the perchloride o f iron

,seven drachm s o f

artific ial gastric juice was divided into three parts and used lo cally every

gay for three weeks . U ltimately the ulcers were completely healedy it .Dr . Routh writes Brit . Med. Aug. 1872 ) in favour of

gastric juice foruterine cancer. The effects which he has observed to beproduced by the juice on cancerous so res have been so lution of sloughs,

384 REPORT ON MIDWIFERY , mid.

they have been long acting, gradually elongating the attachments , andstretching and elongating the o rgans them selves , o r parts o f them .

T he pelvic viscera descend either from the retaining fo rces beingdim inished o r the expelling fo rces being predom inant . That which ismo st easily displaced w ill descend first, and the rest will fo llow in theexact order and in the exact duration Of the facility with which theymay be depressed.

Dr. Duncan,in a paper on the functions Of the perinaeum in pro ci

dentia uteri E din . Med. J Feb . believes that the perinasum has n o thing to do with the maintainance o fthe uterus in its naturalpo sition

,and that laceration Of it has no causative influence in the pro

duction o f pro cidentia . There can b e no doubt, however, that laceration Of the perinaeum favours o r accelerates the o c currence Of pro ci

dentia . It abbreviates the latter part o f the path which the uterustravels in its descent . It abets the causes which produce pro lapsus byremo vingdifficulties which o therwise wo uld have to be o verc ome. Thesedifficul ties lie not only in the length and resistance o f the perinaeum ,

but

also in the smallness and tightness Of the vaginal o rifice. RestorationOf the perinaeum do es no t remove any cause o f pro lap sus o r pro c identia .

It is resto red in o rder that it may resist the progress o f the descendinguterus . This Oppo sing power o f the perinaeum may be increased by thepressure o f the pad o f a T bandage.

Dr. Squarey writes Obst . Trans ,on the causation o f ac

quired flexions Of the uterus . His o bject is to explain why in two

cases, the same causes and c onditions apparently existing, an anteflexion

is found in the one case, a retroflexio n in the o ther. He p o in ts out thatin whatever plane o f the pelvis the uterus is situated, its axis isinvariably at right angles to that plane, and he believes that the dirc otion the fundus uteri takes in a flexio n depends on the situation o f theuterus in the pelvis at the time that the cause produc ing it c omes intoaction . When an anteflexion is produced, the uterus is high up , theaxis being fo rward, and any fo rce striking it from abo ve would impingeo n the po sterio r and upper surface o f the fundus, and so fo rce it fo rward, pro duc ing anteflexion . When retrofiexion is produced the uterushas from some cause sunk m ore o r les s deeply into the pelvis, and hasits axis directed mo re o r les s backward

,s o that any force striking it

from above would impinge on the anterio r and upper surface Of thefundus .Dr. Rasch writes Obst . 1871) on a no vel method o f us ing

the uterine sound for redressing a flexed uterus . T he sound introduced into the retroflexed uterus should first be used as a lever to liftup the o rgan ; then, ins tead o f twisting the handl e round

,the part in

the uterus and its ideal pro longation are made the c entre o f m o tion,

round which the handle and stem sweep in a large c ircle . T he m o vement is well illustrated by grasping the curved part o f the s ound inone

’s hand and swinging the handle round as it will go . By theabo ve metho d the irritation which results from making a large sem icirc le Of mo tion in the uterine cavity i s avo ided.

The mechanical treatment Of disp lacements o f the unimpregnateduterus is fully described by Pepper Amer. Journ . o f 187 1 )

b isnxsns or THE VAGINA ; 385

es Brit . Med. J Sept . 187 1) an accurateatomical c onditions c onnected with hypertro phicix uteri . The who le pelvis and its co ntents ino ved after death , and a vertical section was made

The fundus and body were somewhat lower in the pelvis thanthe body had undergone apparently very little elongation .

lips o f the o s uteri were much hypertrophied and somewhatthey fo rmed a mass co vered by the everted vagina o utside the

vulva . The base Of the bladder was carried down along with the downgrowing interior wall o f the cervix uteri

,fo rming a sacculated p ouch

below the level o f the urethra,and

,therefo re, below the symphysis

pubis . The urethra was also distorted into a curve,o f which the c on

vexity lo oked upwards, the bladder end o f it being carried downwardsalong with the base . The peritoneum ,

descending behind the abdom inal wall, was reflected upwards o ver the bladder (the cavity o f whichwas enorm ously enlarged) at a p o int about two inches abo ve the sym

physis pubis . It descended beh ind the bladder quite down to a p o inton a level with the sac culated p ouch o f the bladder, that is, below thelevel Of the lower m argin o f the symphysis pubis . Rising o ver thefundus uteri, the membrane descended behind, fo rming a Douglas ’spouch quite below the vulva . Dr. Barnes po ints out that it would no thave been p o ss ible to rem o ve m ore than a po rtion o f the o s witho utOpening the retro -uterine p ouch . The spec imen also explained the

difficulty c omm only-encountered in keep ing the pro truded parts insidethe pelvis by pessaries .

“

NO fo lds of intestine descended between the

pelvic viscera in the anterior o r the po sterior peritoneal ‘

p ouch .

Barnes also writes St. Thomas ’ s Ho sp . 1871) on the

hypertrOphic po lypus o f the o s uteri,and its relation to hypertrophy Of

the cervix uteri . ” Cervical hypertro phy is known frequently to pursuea very unifo rm c ourse, affecting the who le structure Of the cervixalike but sometimes one lip , and sometimes even a part o f one lip, ism ore espec ially affected. A small lobe c ontinues to grow under the

same stimulus that determ ines the general hypertrophy . It grows alittle more quickly, then its base, being c om ressed by the firmstructure o f the o s on either side of it

,is squeeze and elongated until

it assumes the characteristic po lypo id shape . The structure o f thesehypertro phic po lyp i entirely acc ords with this theory Of their formation . They are generally small, but sometimes as large as a cherry ;c ommonly single, but it is not infrequent to find two or three, and someshow a tendency to lobulation .

Diseases of the Vagina .

Winckel gives Arch . f. 11, 3 , 187 1) an analysis Of fiftycases Of vaginal cysts , inc luding four under his own care. The cystsmay be divided into three kinds muc ous cysts , o riginating eitherin open o r c lo sed fo llic les ; (z) interstitial, submucous, o r p laced inthe fibrO -muscular layer ; and (3) sub -serous, situated abo ve, in the

peri-vaginal connective tissue underneath the peritoneum , below,25

386 REPORT ON MIDWIFERY , Ere.

between the vagina and the rectum . The chief causes o fcysts are catarrh, inflammation o f the vagina, and thehyperaem ia which it undergo es

hen’s egg in seven or eight years . The

generally cause but little inconvenience .

his cases by simple in c ision . T he o thermended are the exc ision o f a p ortion of

quent app lication Of caustic , puncture and injby the écras eur, and the use Of a seton .

Vagina l stenosis is illustrated by E bell, who relates a case Of

c ontraction in the upper third after cho lera, and by Martin ,

reco rds two cases . Beitr. zur Geb . u . Berlin ,

Gueneau de Mussy writes on hyperaesthesia o f the vulva and

nismus . He disapproves entirely o f S ims’ method,and believes

medical means combined, if necessary, with dilatation render deepsions altogether unnecessary . He has Obtained go od resultsvaginal suppo sitories o f brom ide o f po tashtaneo us injection of m orphia and atro pia . Whenac companied by itching he gives also some arseniate o f soda .

Médical,’Sto ltz writes Gaz . Med. de Strasbourg ,

’16

,1871) on

thesia and spasmodic contraction o f the vaginal sph inc ter,without fissure . Vaginismus is also treated o f by Scharlau .

zu . Geb . und p . 64, On vaginal neuro sis .Berl . Klin . viii

,I 5 ,

Dr . Byrne related to the Dublin Obstetrical So c iety a caseo f the vagina. The patient was thirty-six years o f age, the m

four children . The tumour was firm , about the size of a

pale in c o lo ur, quite mo vable . It was attached to the o sterthe vagina, and appeared to be fo lded up in a large o o se fo ld of the

mucous membrane. A V -shaped incision through the mucous membrane having been made

,the tum our was carefully dissec ted out o f the

cellular tissue in which it lay . The tumour was lo st , and s o its m icrosc opical characters were no t ascertained. (

‘Dublin Quart. JMay,Dr. Barnes remo ved a fibroma, the size o f a large o range, from the

anterio r wall of the vagina . Its attachment began just at the meatusurinarius , extending along the anterio r vaginal wall, but leaving a spaceo f an inch quite clear below the o s uteri . Obst .Mr. Lawson Tait figures Med. Times and March, 187 1) two

needles, suitable for use in o perations for vaginal fistulae. One needl e

i s the o rdinary tubular one o f Simpson , which , in making a stitch , Mr.

Tait always introduces first by the left hand. He then makes slighttraction o n the wire so as to lift its lo op up from the p o int Of theneedle, and intro duc ing the o ther needle through the o ther flap oppo sitethe first, the wire is easily caught in its no tch and the stitch completed.

REPORT ON MIDWIFERY , Ere .

chron ic . From a clinical po int of view we canno t recognise thedivis ion into fo llicular, parenchymatous

,and peritoneal . S lavjan sky

c ontributes an artic le on the sam e subjec t . Arch if. iii , 2 ,See also Matthews Duncan . (

‘E din . Med. Sept .Dr. E dis relates a case o f ab s cess o f the o vary in a girl set . 1 2 . The

right o vary was fo und to b e distended to the S ize_o f an o range , its

walls were much thickened and c o vered intern ally‘

by flaky purulentlymph ; the po sterior surface had given way, allowing the m atter toescape into the peritoneal cavity . There was also general chronicperitonitis . Ob st . Trans . ’Pro fesso r Gaillard Thomas rec o rds (‘Amer . Journ . Of Obstetric s

,

’

187 1) five cases Of ma lignant disease of the ovaries . He c oncludes thatthe c ircumstanc es which m o st prom inently p o int to the existence o f the

disease are T he rap id development of a so lid tumour in an o vary,with marked depreciation o f the strength , vital fo rces, spirits, and generalc ondition Of the patient. (a) The o ccurrence Of oedema pedum and

spanaemia at an early perio d, and c onsequently dependent up on a

general blo o d state, and no t the c onsequence o f pressure by the tumour .

(3) Lancinating and burning pains through the tumour. (4) Cachecticappearance . 5) The o c currence Of asc ite s without evidences o f

hepatic , renal,o r cardiac disease, o r o f chronic peritonitis ; the fluid

accumulating in such large ,amounts as to fo rce aside the supernatant

intestines and pro duce dulness in place o f resonance on percussion indorsal decubitus .Dr. Brown records a case o f so lid cancer o f the o vary . The tumourweighed n ineteen pounds . On section it was found to b e tough andfibrous in structure

,and to have in its interio r a few Small cavities

containing a purulent-lo oking fluid. T he m icro sco pical appearancesc lo sely resembled tho se found in many sc irrhous cancers Of the breast .Amer. Jo urn . o f May,Dr. Parry writes an interesting article on sudden enlar ements o f,

and haemorrhage into , o varian cysts . Amer . Journ . o f No v.

187 1 )Palm relates twenty-five cases o f o varian cysts in which from ex

cessive distension o f the cyst wall,o r from some traumatic cause ,

rupture o f the cyst o ccurred. Seven o f the cases,were cured, five after

the first, two after repeated rupture. E ighteen died ; three from

c o llapse, six from acute peritonitis , three from chronic peritonitis , andsix from dro p sy and marasmus . W iirtt. Medic . 37 ,Dr. J . J . Phillips po ints out (‘Obst . 1872 ) o ne source o f

danger in treating suppurating o varian cysts by drainage . The c on

traction o f the main cyst makes such traction upon any adhesionsthere may be around a sec ondary cyst that rupture o f the latter maytake p lace . A case is given in illustration ,

and as the contents o f theruptured cyst were purulent fatal peritonitis o ccurred.

Ovariotomy.

Mr. Spencer Well s has lately Med -Chin Nov. 1872 ) com

pleted the analysis o f 500 cases of ovario tomy performed by him . In

OVARIOTOMY . 389

25 cases bo th ovaries were remo ved at one Operation, and there werefour cases where o vario tomy was perfo rmed twice on the same patient .The subsequent history Of patients who rec overed after remo val o f one

o vary pro ved that they m ight menstruate regularly, and m ight bearchildren Of bo th sexes, o r twins and that after remo val o f bo th o variesthey did not become excessively fat, nor lo se their fem in ine appearance o r sexual instinct . Of 373 women who reco vered

, 36 who wereunmarried at the time of the operation had m arried S ince o f these 15had had one child

,6 two chil dren , 3 three, 3 four children , and 2 had

had twins . Of 2 59 who were married when the Operation was per

formed, m any being beyond the age Of child-bearing, 2 3 had had one o r

m ore children since. Seventeen had died Of causes m o re o r lessdirectly c onnected, and 19 of causes not at all c onnected, with ovariandisease or the operation

,at various perio ds from a few weeks to eight

years after o vario tomy. Mr. Wells stated that unilo cular cysts Oftendisappeared after a simple tapping. They were frequently no t o varianat all

, but c onnected with the parovarium o r the bro ad ligament . Hisviews as to early o peration had become m odified from tho se which heat first held. He had found that the results Of Operations on smalltum ours in healthy women were n o t so favo rab le as in cases wherethe cysts were large, and the patients had bec ome accustomed todisease . He did no t think it right to rem o ve small o varian tumours

,

unless they caused great pain and inconvenience to the patient. Brit .Med. Dec .

Keith c ommunicates Lancet, ’ No v. 1872 ) a third series o f fiftyc ases o f o vario tomy . Of the last hundred c ases Operated on by Keiththere have been eighty -four rec overies . There were only eight deathsin the fifty c ases n ow recorded ; two died from o b structed intestine

,

one from acute septicaemia, and five from peritonitis . Keith now takesperhaps m o re care than ever during the operation to tie every bleedingp o int, Lister’ s animal ligatures being used. Pure, dry, sulphuricether is always used by him as an anaesthetic .

A tabular statement has been published o f the cases Of o vario tomyperformed by the late Dr. SkOldberg o f Sto ckho lm . Out of thirty c ompleted cases twenty-six rec overed. An exploratory inc ision was made

in four cases , and o ne o f these died. An operation for the remo val o fa so lid c ancerous o varian tumour was fatal .M r. Christopher Heath related to the Clinical So c iety (Nov . 187 1)

a case o f o vario tomy in which very exten sive adhesion s to the sur

rounding structures were found. On enlarging the abdom inal inc isionwith sc issors in the o rdinary way, an empty c o i l Of small intestine,which was c lo sely adherent to the wall , was divided in three quarters o fits c ircumference . Mr. Heath attached the b owel to the skin withsilk sutures, fo rm ing an artific ial anus . T he patient m ade a perfectlygo od reco very, the us e o f a belt and an air pad satisfactori ly retainedall faecal matter, and she had regular sto o ls .

Dr. Beebe relates five cases o f o vario tomy in which he treated theedic le by simple to rsion o f its vessels . There was no subsequenthaemo rrhage , and each case recovered. Amer. Jour. o f Med.

April,

390 REPORT ON MIDWIFERY , ETC .

Dr. Atlee records seven cases o f o vario tomy, and describes a new

c lamp fo r the Operation . By means o f this c lamp the pedicle is c ompressed in the linear direction o f the wound, and at the same time itlim its within c ertain po ints the expansion o r spreading o f the pedic lewhen the blades are screwed together. (Ibid.)A new o vario tomy c lamp is des cribed by Dr. Dawson Amer. Jour.

and a pump for fac ilitating the o peration by Dr.

Lente.

Dr . Tracy repo rt s six cases o f o vario tomy, five o f which were suc

c essful Austral . Med . Aug. and a successful caseperformed during an attack o f peritonitis . Med. Chir .Dr. B . S . Schultze relates Arch . f. ii

, 3 , 187 1) fourcases, two Of which reco vered. One Of these patients had two

children subsequently ; the o ther menstruated through the abdom inalwall, and the discharge from the site Of the inc ision o ften lasted somehours longer than that from the vagina . Martin also contributes sevencases . Berl . Klin . March,Dr. G . H . B . Mac leod writes Lancet,’ Jan . 1871) on an impro ved

method of dividing the pedicle in o vario tomy, and describes an instrument o f his own construction which he employs to grasp the pediclefirmly near its uterine end. The cyst is then cut away by dividingwith a knife the extreme distal end o f the pedic le, and the stump iscaught by special fo rceps at a short distance from the part grasped bythe instrument abo ve mentioned. By slowly turning the forcepswhile the first instrument is kept at rest , the stump is twisted o ff

c lo se to the edge Of the instrument b which it is held,

d may thenb e returned with safety into the a dominal cavity . Dr. Macleodrelates a successful ca se in which this plan was adopted ; the patientwas quite reco vered about the time the c lamp i s found to separate inm o st cases . He says that it i s a question fo r further o bservation howfar the s imple grasp Of the first instrument, if continued for a shorttime, m ight suffice to c lo se the vessels o f the pedic le without thetorsion . Mr. JesSOp relates Lancet, ’ Sept . 1871 ) two cases in whichthe pedic le was successfully twisted by the abo ve method.

Dr .Hayes recommends a method for securing the vessels o fthe pedic le,which he calls “ the subperitoneal . ” T he pro ceeding resembles thesubcutaneous ligature Of naevus . The pedic le is first c ompressed by ac lamp

,and a needle armed with stout catgut ligature is passed

beneath a go od thickness o f the serous surface of the pedicle, butsuperfic ial to the prin cipal vessels . The needle being withdrawn at

the side o ppo site the p o int o f entrance is again passed into the aperture o f exit, and pushed between the vessels and peritoneal co vering on

the side Of the vessels Opp o site its first passage, until it can be withdrawn through the o pening made by its first entrance . The ends Ofthe ligature are to be strongly tied, and cut Off sho rt. (

‘DublinQuart . J N ov.

Panas relates a suc cessful case of o vario tomy in which a subperitoneal fibro id o f the uterus was removed at the same time. Gaz . des

JulyMr. Lawson Tait has introduced a new fo rm o f tro char for use in

892 REPORT ON MIDWIFERY , ETC.

and three ounces of a c lear limpid fluid escaped. The sac was thenfreely laid open, but no intestine o r omentum was fo und. Two similarc ases came under the no tice of Dr. Nelson

,and in these there existed

the same translucency, slow growth, non-reducibility , and freedom

from pain .

In a paper on uterine inflammation after the change Of life Brit.Med. J Sept . 1872 ) Dr. Tilt states that the o ccasional recurrence after the menopause o f inflammation Of the sexual muc ous mem

brane may be safely predicted to tho se who have long suffered frominflammation of the entire womb , when they presume to o much on theirpartly reco vered strength. Also that we may safely predict inflammationo f the sexual muc ous membrane to tho se who o vertax their strengthafter the m enopause, whenever the uterine tissues are teased by thepresence o f a small interstitial fibro id o r a po lypus, when the cervix ishypertro phied, and also when the women are cachectic and havealways o ne o r m ore Of their muc ous membranes in a diseased condition .

In a discus sion on uterine injec tions for chronic metriti s at theSo c iété de Médec ine o f Paris M . Charrier recommended io dine ; theperchlo ride Of iron , he said, gave rise to excessive ain . Gallard spokehighly Of a weak so lution o f the perchloride .

IHe firs t in '

ects the

uterus with water s o as to ascertain Its capac ity,and afterwards m eets

at

?

similar quantity o f the so lution o f the perchlo ride. Gaz . desHJOp

eb .

Pro fessor Spiegelberg contributes Arch . f. iii,2 , 1872 )

three cas es illustrating the value o f punc ture in the diagno sis o f co lleetions o f fluid in the abdomina l cavity. Having referred to a previouscase repo rted by him where the om is sion o f tapp ing led to the error o f

m istaking a hy datid cyst o f the kidn ey fo r an o varian tumo ur, and to

an o peration and the death o f the patient, he quo tes z—Case I .—A

woman, set. 30 , two years previously, after SO -ca lled abdom inal inflamm ation

, no ticed a swelling in the left hypogastrium ,which

increased slowly and steadily, b ut which gave rise to little annoyance

, except to fixed pain in the left side. On adm ission a cysto c cupying the centre part o f the lower and m iddle abdomen ;doubtful o rigin ; puncture, evacuation Of pus ; attempted inc is ion ; andrupture o f cyst after detachment o f neighb ouring adhesions ; escape o f

echino co ccus membrane ; retro peritoneal left-sided hydatid cyst partialexc ision,

the rest attached to the abdom inal wound ; rec overy by wastingOf the sac after long c ontinued suppuration . Case 2 ,

—JE t . 40 , sentin fo r o vario tomy . Puncture Of one o f the cystic spaces revealed itno t to b e an o varian tumour

,for the small quantity o f dark fluid wi th

drawn , besides c ontaining many red and white blo od-cell s,underwent

spontaneous c oagulation and showed no epithelial elements . The serouscharacter was thus apparent . Death by marasmus and oedema o f the

lungs . Tum our found to be a large retroperitoneal and mesentericsarc oma des cending into the pelvis, and resembling an o varian cyst onac c ount of numerous sacculated asc itic spaces and secondary adhesionsto the fundus uteri . Case 53.—flit. 2 8, with an abdominal tumour, itscharac ter doubtful . By tapping a glutino us fluid was withdrawn,

wh ichcontained besides crystals o f cho lesterin, numerous cells, a little débris ,

0

PHY SIOLOGY AND PATHOLOGY or THE OVUM. 393

cells with clear contents, and much remarkably distinct nuclear cylindrical epithelium . This po inted to its o varian character. Ovario tomy

,

inc omplete on account o f numerous adhesions . Death by dec om

po sition Of cyst . Sp iegelberg c onc ludes that although diagno sticpuncture do es no t always give po sitive information as to the o rigin or

the fluid, yet that when it do es the result is conclusive as comparedwith the doubtful physical examination ,

II . PRE GNAN CY .

P hgsio logg and P atho logg of the Ovum.

Dr. Livius Furst writes Arch . f. 11, 3) on the amnion in

its relation to foetal malfo rmations . WhIle he admits that compressionby the umbilical co rd may, in some cases, be the cause Of arrest o f

development o f certain p ortions Of the foetus, he believes that amnialfilamentous adnexa —under which name he inc ludes thready, stringy

and membranous formations—are the mo st c omm on causes Of mechani

cal interruption to the development o f the foetus . He then discussesthe fo rmation Of these adnexa ; by some they are regarded as plasticadhesions, by o thers as the result o f foetal inflammation with p lasticexudation,

but Fiirst agrees with the theory which c ons iders them due

to arrested fo rmation o f the amnion . The inner layer Of the amnion,

at first in clo se c ontact with the foetus,is g radually separated from it

by the liquor amnii ; but abno rmal adhes ion m ay take place betweenthe epithelial layer o f the amn ion and the epiderm is of the foetus, andthis

,by the expansion Of the amnion, leads to thready and stringy

fo rmations,wh ich may who lly o r partly interrupt the development Of

the extrem ities . The m o st frequent cause o f this adhesion is the smallquantity o f liquo r amnu , o r its late secretion .

In the discussion on a spec imen exhibited at the Obstetrical So c ietyof a child who se fo rearm had undergone amputation in utero , Dr. Barnessaid that it was no t o ften strangulation by the umbilical co rd‘ thatcaused these amputations , but by a string o f false membranes . He

regarded the budding from the stump which is so Often fo und, with thesigns of a c icatrix, as pro o f o f amputation in the early stage Of development . Obst .Dr. Braxton Hicks writes on'

the anatomg of the hmnanp lacenta , andcontro verts the Hunterian do ctrine. He shows h ow the injection whichHunter used would almo st certainly pro duce an irruption o f blo o damongst the villi . The fact Of blo od being found am ong the villi afternatural expulsion is no evidence in favour o f or against a sinus system ,

because there are then nearly always lacerations and denudations o f thedec idua sero tina . The autho r argues that if no blo od be found am ongthe villi, the p lacenta being examined in s itil

,this is c onclusive evidence

against the existence Of the sinus system . Dissections proving theabsence Of blo od under these circumstances are added. O bst.1872 )

394 REPORT ON MIDWIFERY , ETC .

Joulin contributes some Observations on the lam inar membthe human placenta, the state o f the chorion ,

and the placentaltion at term,

and conc ludes that at the end

has dis appeared as a c ontinuous membranethe placenta , and that the greyish resisting tissue which co vers theplacenta is not the chorion, but a membrane o f new fo rmation, whichhe c alls the lam inar membrane . He illustrates the evo lutio n o f thismembrane by reference to the c ondition o f the placenta at variousstages Of its development . Bulletin de l

’

Académie de Med. de

Paris,’ March ,An interesting case of recurrent discharge o f fluid from the uterus

during pregnan cy is rec o rded byDr. Dyce Brown Brit .Med. JMay, The first gush o f c lear fluid

,just tinged with blo od, to ok

place at the fourth m onth, and was repeated almo st weekly until thesixth month, when lab our came on . The amnio tic sac was then felttense, and required to be ruptured, after which a large quantity o f fluidescaped. A similar discharge has o c curred in the two subsequentpregnancies Of the same patient . Fabbri writes Presse xxiii

,

29 , 187 1) on the hydro rrhoea o f pregnancy.

Dr.Matthews Duncan writes on long delay o f labour after discharge Ofliquor amnii . He gives an illustrative case, and refers to the researcheso f Winkler, pro ving that the amnion has the power o f secretion and

ab so rption in a high degree. Firm compression o f the foetus may takeplace without active uterine contraction

,and it is firm compression by

active uterine co ntraction that is incompatible with the c ontinuance o f

pregnancy . Obst . Similar cases are also reco rdedby various writers in the ‘British Med. J and by DoughtyAmer. Journ . Of May,In the Gaz . Med. de Paris,’ O ct. 187 I , is an account o f some peculiar cgstsfof

‘

the p lacenta described by M . Jacquet . He believes thatthey were developed at the expense o f the sheath o f the placentalvessels, and he calls them perivascular cysts . Jacquet adm its four kindsof placental cysts—( I) gelatinous cysts o riginating in the laminatedtissue between the chorion and the amnion ; (a) perivascular cysts(3) sanguineous cysts, from the placental s inuses ; and (4) the o rdinarycysts Of the villi (hydatinifo rm degeneration) .

On ca lcification of the p lacenta—Dr. E . Frankel gives Arch . f.

ii, 3 , 187 1) three cases in which a careful exam ination Of theplacenta was made ; and he concludes that calc ification o f the placentamo st frequently fo llows the c ourse o f the capill aries and small vesselso f the villi, though it may b e mo re diffuse and intermediate, and thenits origin , ac c ording to Langhans , is from the epithelial layer of thevillous trunks . Mo st comm only capillary incrustation pro ceeds fromthe vessel wall, spreads through at all po ints

,and fo rms

, as it were, aco ating fo r the cavity o f the vessel, witho ut as yet rendering the ves selimpervious . It usually, though not always

,begins at the extremities

of.

the villi, and may al so show itself at separate po ints in the trunks .D iffuse, no t tOO extensive

,calc ification is without influence on the support Of the foetus, while, indeed, a less extensive capillary petrification ,

especially in the earlier months Of pregnancy, interferes with the foetal


generally said that the uterus descends in the last month . Schmidt ’sJahrbiicher, ’ B . c lii , H .

Dr. Hutton states (‘New Y o rk Med. J July, 1872 ) that hehas been able to predic t the sex o f the child in utero in seven cases, without a failure, by aus cultation . When the foetal pulsation s number 144

per m inute the child is a female ; 1 2 4 per m inute, a‘

male. A variationo f six beats per m inute, from 1 2 4 upward and from 144 downward,will no t endanger the diagno sis, pro vided auscultation b e practised inthe n inth m onth o f pregnancy . Of fifty

-seven cases exam ined bySteinbach he was correct in fo rty-five, and Frankenhausen was c orrectin all the fifty cases which he examined with a view to determ ine thesex o f the child.

Dr . Brunton relates a case Obstet . 187 1) in which theentire o vum was expelled at the seventh m onth , and although at leastfifteen m inutes elapsed befo re themembranes were Opened, yet the childwas rescued alive . Dr. Heywo od Smith did no t see why the childshould no t have been alive. It was no t in the condition o f a child bornwith the stimulus o f the external air pro duc ing inspiratory effort, ands o incurring the danger o f drowning, but in this case, with the ex

ception o f‘slight lo ss o f heat, the child was in a natural c ondition, its

circulation continued a s if it had been still in utero , with the sub stitu

tion merely o f aeration by the atmo sphere, acting direc tly upon the

uterine aspec t Of the placenta, for the maternal blo od. Dr. Grigg saidthe prac tical lesson from the case was to take care

,should the placenta

b e expelled befo re the birth Of the child, to expo se its uterine surfaceto the air.

Concep tion under unusua l circums tances . Dr . R . O lshausen re

lates Arch . f. 11,a,187 1) two cases in which c onception

o ccurred while each o f the patients was wearing an intra-uterinestem . The first case was that o f a woman who , since her last c onfinement

,had suffered from meno rrhagia and anteflexion o f the

uterus , fo r which an intra-uterine stem pessary was introduced on the

a8th Of June. She menstruated fo r the last time on the 6th o f December, and was delivered Of a strong b oy on the a5th o f September. The

instrument was remo ved on the 15 th Of January, c onception having probably o ccurred about the 19th o f December. The second patient hadsuffered from perimetritis after her last labour, and had anteflexion o f

the uterus, for which she wo re an intra-uterine stem . Menstruation wasregular and profuse ; the last periodwas on the 8th Of September. The

pessary was remo ved on the 18th o f O cto ber, and she was confined o f

a girl, weighing 4: kilog. , on the a4th o f June . The o vum and the

instrument were probably twenty days together in the uterus in thiscase. The pessaries were made o f hard caoutchouc

,with a globular

head.

D iseases of P regnancg .

Dr . R . Kaltenbach writes an elaborate artic le on albuminuria and

diseases o f the urinary o rgans in the child-bearing period Arch . f.

iii, I , He relates cases as pro ofs Of each propo sitionwhich he lays down, and sum s up his researches in the fo llowing c on

DISEASES OE PREGNANcY. 397

supervene (I ) in c ouseesults from pres sure on

from genera l catarrh o f

the urinary passages , with pyelitis ; (3) in c onsequence o f c ongestion o f

the renal vessels and (4) from parenchymatous diseases Of the kidneys .In the puerperal state album inuria may result ( I) from ves ical catarrh ,bro ught on by the mechan ical irritation o f a catheter, o r by the extension o f the inflammatory pro cess from the genital o rgans t o the bladder,o r by severe labour ; (2 ) from general catarrh Of the urinary passages ,with pyelitis , aris ing from a simple extension o f a primary catarrh o f

the bladder,o r from c ontiguity to inflamed parts, while sometimes

pyelitis may su crvene as an independent idio pathic affection ; (3) fromcongestion o f t e renal vessels as in uncompensated insuffic iency o f

the valves o f the heart ; and (4) from textural disease o f the kidneys ,which may appear as a primary parenchymatous nephritis , o r b e

secondary to the extension of inflammation from the bladder, or resultfrom pressure on the ureter, or be the m etastatic inflammation o f pyaem ia . Physio logical albuminuria do es no t exist either during pregnancyo r in the puerperal state .

Dr. Hermann Lebert,Of Breslau, relates three cases, intended as a

c ontribution to our knowledge o f the causation o f heart disease and

disease o f the vessels in c onnec tion with child-bearing :

Case 1.

—Acute articular rheumatism at the fourth month o f pregnancy, symptom s Of m itra l endo carditis , repeated rigo rs , indications o fembo lism in the left lower and the right upper extrem ity, abo rtion ,

deathfrom oedema o f the lungs . E ndo carditis with ulcerative destruction o f

the bicuspid valve, embo lic Obstruction o f the subc lavian artery, o f theterm ination o f the ao rta, and o f the first part o f each iliac artery . The

uterus was full o f blo od-clo t, but no patho logical change existed in itswalls . Case 2 .

—Severe puerperal fever, great dys noea,with abundant

rhonch i and a bellows murmur in the vic inity O the tricuspid valve.

On opening the body there was found purulent inflammation o f the

tricuspid, a large embo lism in the right po rtion o f the pulmonaryartery

,with purulent inflammation of the same . The inner surface

o f the uterus showed a well-marked unifo rm injection Of its vessels ,with everywhere a rather thick epithelial layer. The o rgan was twicethe size it should b e at the fifth week after labour, but its structureappeared no rmal . There was inflammation o f the right spermatic vein .

Case 3 .

—Abo rtion at the sixth m onth, perio varitis , p leurisy, swelling

o f right knee and left elbow ; death on the twenty-fourth day . E m

b o lism in the pulm onary artery,double pleurisy, gangrene o f the lower

lobe o f right lung, thrombus o f vena cava inferio r, Obstruction o f the

left renal vein ,perio varitis , periuterine purulent phlebitis, and endo

metritis . Arch . f. iii, I,

Dr. A . Gusserow relates Arch . f. 11,a,1871) five very

interesting cases o f a high degree of anaem ia in pregnant women . The

character o f the symptoms and the cause o f the disease were strikinglyalike in all . The age o f the patients varied from twenty-four to thirtysix ; they had previously enj oyed go od health , and four o f them had

been before pregnant. Slowly, in the course of pregnancy, and with

REPORT ON MIDwIEERY , ETC.

out any apparent cause, there supervened such severe anaemiahydraem ia

,that towards the eighth month the foetus was expelled,

each patient died so on after. In none o f the organs c ould beo

found

any marked change except the appearances o f extreme anaemia and

hydraem ia and their c onsequen ces . The brain and Its membraneswere very anaemic . The slight fatty degeneration Observed (thoughno t in all the cases) in the substance of the heart and in the abdom inalvi scera was, he bel ieves, simply the result o f the blo od-change, and no tthe primary cause. The alteration s which are known to o ccur in the

blo od during pregnancy seem ,in these cases

,to have been carried so far

as to become a patho logical c ondition . Gus serow rec ommends, In

similar cases , that abo rtion should b e induced, o r at least, as early aspo ssible

, prem ature lab our. Transfusion may be necessary .

Matton,o f Bouzonville, writes Journ . de Bruxelles, ’ May and June,

1872 ) on pneum on ia during pregnancy and on puerperal fever. In thefirst place the author c onsiders the m o difications whi ch pregnancy 1n

duces in the blo o d. These c onsist in an increase o f the fibrine and the

water,and a dim inution o f the c orpuscles and the albumen ; thus preg

nancy predispo ses to inflammations . If the am ount o f fibrine exceed

certain limits, we have, succeeding to the inflammatory, the purulent

diathesis , and if it is the watery part which is increased beyondmeasure

, we have in addition a serous cachexia. According to Andralduring the first six m onths Of pregnancy the amount o f fibrine isdim inished, and is met with in increased quantity only after thesixth m onth . Matton then quo tes thirty-eight cas es o f pneumoniaduring pregnancy, and states that nineteen cases out o f twenty re

c overed when the pregnan cy was no t interrupted in its c ourse, but onlynine o ut o f eighteen go t well when labour supervened. Fo r him puerperal fever is the combined result o f an essential fever o f internal origin,due to the condition o f the blo od and o ther ill-understo od causes, and alo cal phlegmasia .

Spiegelberg writes on the complication o f pregnancy with chronicheart disease. (

‘Archiv . f. ii,a,

Comp lications and Accidents of P regnancy .

Dr. Madge repo rts Brit . Med. Dec . 187 1) a case ofparalysis during pregnancy . At an early perio d in the pregnancy thepatient c omplained o f severe pain in the hands and feet

,which s

became excessively sensitive and painful . In a few weeks this hyper.

aesthesia was succeeded by anaes thesia, and there was also lo ss o fmo tion . Small do ses Of ergo t o f rye were taken for several weekswithout any erceptible benefit ; this was o rdered on account o f itscontractile e ects on the smaller vessels

,thus lessening congestion,

which it is believed existed in this case in the grey matter Of the chord.

Faradisation was then used, and sensation returned in two months,

but mo tion no t until later. A dead foetus, o f about fo ur months,o f

a dark muddy c o lour, and surrounded by muddy liquor amn ii wasultimately expelled. T he patient made a go o d reco very.

Dr. Playfair po ints out (‘Obst . xiii) that some cases of

400 REPORT ON MIDWIFERY , ET'

c‘

.

then placed a heavy weight on her abdomen, is related by Biggs.

Western Lancet, ’ Aug .

A case o f exfo liation of thefema le bladder is recorded by Dr.Wardell .The patient was twenty-eight years o ld, and about three m onths pregnant ; retention o f urine fo r five days ; abo rtion . On the twelfthday she c omplained o f great pain o ver the pubes . A membranous m as swas seen to pro trude through the meatus urinarius ,

'

and this was fullyexpelled in half an hour. On exam ination it seemed as if the who le o f

the mucous c o at Of the bladder had been thrown o ff. T he patient made

a go od reco very . S im ilar cases are reported by Dr. J . J . Phillip s,who po ints out that retrovers ion o f the gravid uterus by leadingto retention o f urine is one cause o f the ac c ident ; by Mr. Spencer

Wells , who se two cases o c curred after severe cystitis fo llowing p arturition ; and by Mr. W . Whithead, wh o states that muscular fibreand serous tis sue are o ften attached to and inc orporated with the

muc ous lin ing expelled. Brit. Med. J June I O , 2 4, July I,and

O ct. 14,

Dr. Crraily Hewitt co ntributes Obst . 187 1) a paper on

the vomiting qf'

pregnancg , and believes that it results from flexion o f the

uterus,either fo rward o r backward ; the tissues o f the uterus, including

the nerve ramificatio ns pervading it, being c ompres sed at the seat Offlexion and thus leading to the sicknes s . A somewhat similar view isa lso advo cated by Hubert in the Lyon O ct. 187 1 .

Mr. Metcalfe Jo hns on recommends the sim le hydrated pho sphate o flime, in do ses o f from three to ten grains , in the sickness Of pregnancy.

Med. Times and Jul y,

G imbert writes in favo ur o f the bromide o f po tass ium adm inisteredin large do ses by rectal injection fo r severe vom iting during pregnancy .

He relates a case in which vario us remedies were tried in vain ,but

after three days the above method pro ved very successful . ( ‘Bulletinde

A case Of excessive vom iting at the sixth m onth o f pregnancy isrecorded by Dr. Campbell Bo ston Journal, ’ After variousineffectual kinds o f treatment, the membranes were ruptured, and

relief was speedily Obta ined ; but labo ur did no t c ome o n fo r twelvedays after puncturing the membranes .Pypingsko ld relates two cases Of uncontro llable vom iting during

early pregnancy ; one was kept alive by nutrient enemata , the o therdied without being delivered. LO Sperimentale, ’ Jan .

Mr. Ling records Lancet,

’Sept. 1872 ) a case in which a patient,

four months pregnant, was seized with ago nising abdom inal pains,fo l

lowed by intense syncope and death in twelve hours . The abdom inalcavity was filled with blo o d. A large ho le existed at the fundus uteri,four inches in diameter ; the edges o f the wound were jagged, but thesubstan ce Of the uterus was firm . T he placenta was found with itsattached surface presenting upwards in prec isely the po sition it wouldtake if adhering no rmally to the fundus, and the foetus surrounded bythe unruptured membranes was c ontained in the uterus . T he uterinetissue presented in some parts only spo ilt-lo oking granular remains o fthe muscular structure With extravasated blo od, suggesting an injury

DURATION OE PREGNANCY.

and subsequent lo cal metritis, o r an inflammato ry condition pro duc ingsoftening Of the tissue and subsequent rupture, with extravasation o fblo od into the muscular tissue.

See also a case Of rupture of the gravid uterus at the seventhmonth . Amer. Journ . o f Obstetrics

,

’Aug.

T he Diagnosis of P regnancy .

Dr. Braxton Hicks po ints out that the pregnant uterus po ssessesthe power and habit o f spontaneously c ontrac ting and relaxing fromthe third m onth up to full term . This c ontraction mo st c omm onlyoccurs every five o r ten m inutes , though it may no t recur for half an

ho ur. It is independent o f reflex stimuli . It is useful in pro vidingfor the frequent movement o f the blo od in the uterine sinus and decidual pro cesses, and fac ilitates the m ovement of the fluid in the intervillal space, and it als o adapts the p o sition o f the foetus to the form o fthe uterus . It is o f great value in the diagno sis o f pregnancy .

Obstet .Dr. Wallace advo cates (‘E din . Med . J Nov. 1872 ) the exac t

diagno sis o f the p lacental p o sition by vaginal stetho scopy . In threecases Of flo oding before delivery he has lately had the oppo rtunity o ftesting the value o f this diagno stic m etho d ; and in Case I he progno sti

cated m arginal o r partial p lacental presentation, in Case a c entre fo rcentre

,and in Case 3 no placental presentation whatever . E ach o f these

diagno ses were verified by the subsequent progress o f the labours . He

recommends a long and curved stetho sc ope . The patient is put into theusual Obstetric po sition ,

the nates being well o ver the edge o f the b ed

the stetho sc ope, well lubricated w ith Oil , is passed into the vagina, andp laced first against the OS uteri under the guidance o f the finger. T he

ear can then b e brought into c ontact with the stetho scope without anydiffi culty

,and by carefully m o ving it in all direction s from the o s uteri as

a centre, the who le o f the superio r part o f the excavation,c orresponding

to the lower zone o f the uterus, is explo red in success ion . The bellowsmurmur

,heard by vaginal stetho sc opy in central imp lantation o f the

placenta o ver the OS uteri,has a loudness and distinctness Of character

rather startling to the ear accus tomed to abdominal auscultation .

When the presentation is central the murmur is heard o ver every partOf the pelvic strait . If partial o r marginal , the indication Of the site isequally well marked, and in such instances c ombined vaginal and abdom inal stetho sc o p ic examination will map out with c lear prec ision thesite Of the p lacenta when it has an anterior o r lateral po sitio n . T he

absence o f the characteristic sign s by the abdomen,and the po sterio r

situation o f the vaginal brui t, with its absence in the anterio r and

lateral directions in the superior part o f the excavation,will determ ine

its partial presentation inferio rly, and po sterior situation superiorly .

Duration of P regnancy.

Dr . Matthews Duncan E din . Med. J March , 1871) statesthat prediction of the day Of lying-in is an impo rtant practical matter,from who se arrangement all theory should be excluded. It is a valu

26

402 REPORT ON MIDw‘

IPERY , ETC.

able calcul ation of a quite empirical kind. He refers to Ahlfeld’selaborate memo ir on the duration o f pregnancy Monats . fur

in which the duration is estimated at 2 7 1 days . Duncanrecommends the fo ll owing method —Find the day o n which menstruation ceased

,take that day n ine m onths fo rwards as 2 75 days , unless

February is in c luded, in which c ase it is taken as 2 73 , to this add

three days in the fo rmer case, o r five if February is in the c ount,to

make up the 2 78 days . Out of I 53 cases the day of confinement wasexactly predicted in ten cases in this manner. In eighty cases labourto ok place so oner, and in sixty-three cases later than was predicted .

The average error was about seven and a half days,a c ircumstance

which indicates that the prediction should not state the week, but thefortnight o f delivery .

Abortion and P remature Labour .

Dr . J . J . Phillips contributes a paper on retroflexion of the uterusas a frequent cause o f abo rtion . He states as the resul t o f his Observations that, after making due allowance fo r various c onstitutional causes,a m o st important fac to r in the production Of abortion in many cas es isa retroflected uterus . The increased susceptibility o f the retroflected

pregnant uterus to concussion from sudden m o vements,the mechanical

irritation to which it is subjec ted, the straining in micturition and

defaecation in such cases, and the irritation which the abnormal po sitionsets up, appear to be very eflicient exc itors o f uterine ac tion , whilethe interference with the uterine c irculation tends to the efiusion o f

blo od and death o f the o vum . He relates cases where,after repeated

abortions,the full term o f pregnancy was reached by wearing a Ho dge

’spessary . Obst.Dr. Donaldson relates G lasgow J 1872 ) an interesting case

in which by means o f premature labour induced at the eighth m onth ,the life o f the child was saved, though three former pregnanc ies hadended in the birth o f stillborn chil dren . The death o f the childrenresulted, it was believed, from disease o f the placenta

, which containedthroughout masses Of cheese-like depo sit .Martini recommends chloride Of go ld and o f sodium in the treatment

Of nervous disorders dependent on uterine disease. He believes thechlo ride is also useful in preventing the tendency to abortion . Rev.

Clin . de Boulo gne,’ Jan .

Mr. Bassett confirm s the experience o f Dr. Kennedy that in abo rtion the adminis tration o f ergo t is generally inadvisable. When the

haemo rrhage i s slight, and the case threatening only,ergo t may do

go o d, as also where the o vum is detached and merely wants expelling.

But no m o re regul arity of action can be secured for it in m iscarriagethan in labour . Owing to its uncertainty and irregularity, and its wellknown power Of produc ing contraction o f the circular rather than thelongitudinal fibres o f the uterus, it i s inadvisable to adm inister it inmany c ases o f abortion . Brit . Med. J O ct . I S72 .)Dr. No eggerath relates a case Of abo rtion in which the secundineswere expelled without the foetus ; the latter came away four weeks

,at

least, afterwards . Amer. Journ . Of 187 1 , p .

404 REPORT ON HIDWIPERY, ETC’

.

gestatiOn, of the abdominal fo rm,in which the foetus died at the

seventh m onth without rupture o f the containing cyst . Chronicperitonitis supervened, pulmonary vom icae, c o lliquative diarrhoea, andhectic . Death resulted from exhaustion at the eighteenth m onth fromthe c ommencement o f the pregnancy . (

‘Lyon Jan .

A case o f extra -uterine foetation and superfoetation . (Argles ,Lancet, ’ Sept .An interesting case o f extra-uterine foetation is reported b Mr. John

s on . After an illness o f twelve m onths the general healt impro ved,and c ontinued go od fo r fo rty-fo ur years . At the end o f this time

foetal bones were passed per rectum . Med. Times June,1872 )Peck reports a case o f extra-uterine foetation in which the child

,a

foetus o f four m onths, was delivered by the rectum . So on after the

m o ther’s bowels were relieved a foetus passed per anum . The c ord was

found hanging from the bowel, and po rtions Of the placenta sub se

quently passed away . Peck c on siders the ca se to be one in which thep lacenta was attached to the fimbriated extrem ity o f the Fallopiantube, and the child during its growth by the side o f the rectum gradually led to thinning Of the tissues , and these ultimately gave way afterthe effo rt o f defaecation . Journ . de Bruxelles, ’ Feb . T he

p o st-m ortem appearances in a case o f extra -uterine pregnancy are

described by Dr. M . Duncan . Med. Times and July,1872 )Adam s relates a case Of extra-uterine foetation, in which gastro tomy

was perfo rmed after the full term Of gestation . The pain from whichthe patient had previously suffered ceased at the end Of the n inthmonth . There succeeded a pro fuse purulent discharge from the rec tum,

and po rtions o f the foetal skeleton pas sed by the same channel . Therewas also a fistulous Opening near the umbilicus, from which pus andfaeces escaped. After making an inc ision through the abdominal wallthere was much difliculty in liberating the child

,which was surrounded

by false membranes . There were three fistulous Openings between therectum and the cavity in which the foetus was c ontained. The patientreco vered. Gaz . Med. de Paris,’ xxxii,E dgar reco rds St. Louis J viii

, 4, 1871) a case o f interstitialpregnancy.

Two interesting discussions have taken place at the Obstetrical So c ietyo n the treatment o f extra-uterine foetation Obst . xiii

,xiv) .

Dr. Meadows,in No v. 187 2 , related a case in which a living child was

removed by abdominal section, but an attemp t was made to remo ve thep lacenta and the foetal pyet, and this was attended with such severehaemorrhage that the m o ther died in a few hours . Dr. Meadows c ontended that in al l cases where the diagno sis o f a living and viable childc ould b e made out gastro tomy o ught to be performed

, but that the placenta and the c ontain ing cys t should be left intact. The placentashoul d be left to undergo the slow but sure pro cess o f absorption, itbeing argued that, as by the remo val o f the foetus there is no longer anyphysio logical necessity fo r the placenta, its remo val by atrophy m ightfairly be reckoned upon . Dr. Murray thought there was to o much risk

THE MECHANISM OF LABOUR. 405

incurred in completely c lo sing the abdominal o pening, as recommendedby Dr. Meadows , and leaving the placenta behind without any chanceOf escape. Dr. Barnes and Dr. Hicks agreed that the p lacenta shouldno t b e remo ved, the fo rmer remarking that its non-remo val was theestablished practice, and the latter that in three cases reported by himthe foetus alone had been remo ved.

A case o f double conception, bearing on the question o f super-foetation

, o c curred in the practice o f Dr. Chemery . The patient was fo rtyyears o f age, andwas found to have lo st large quantities o f blo od, amongwhich was a foetus with its transparent membranes entire

,and alto

gether of about the size o f a comm on open-faced watch . The o s uteriwas dilated and ano ther and a much larger foetus was lying with its headpushing its unbroken investments through the cervix ; its birth wasexpected

,but it remained in utero till the full term o f gestatio n . The

one o vum was expelled at the eighth week with all the appearances o flife up to the time, while the o ther (from calculations at its birth)was at that perio d at about the twentieth week . Bo ston Med.

and Surg. Journal,’ April,Two cases Of p reco cious pregnancg . The first case was that o f a

girl, thirteen and a half years o ld. She suffered from puerperal c onvalsions , but ultimately reco vered. The child was living and weighed6 lbs . 8 o z . Med. Reco rd,

’Jan . T he second was that Of

a girl who had never menstruated, and who was eleven years eightm onths and a half o ld at the time Of conception . Brit . Med. JO ct. Dr. Y oung also rec ords E din . Med. J July

,

187 1) a case Of early pregnancy. T he m o ther, at the time o f labour

,

was fourteen years and ten months Old.

III . LABOUR.

T heMechan ism of Labour.

In some Observations on the innerva tion of the uterus (‘Archiv f.

ii , I , Dr. Reim ann,Of Kiew , publishes the resu lt o f

experiments perfo rmed for the purpo se o f determ ining whether uterinecontractions are dependent on the central nervous system . He expe

rimented o n bitches and cats , and subjected the uterus , partly o r wh o llyseparated from the body

,to various kinds o f irritation . He found that

the uterus, separated from the c erebro -Sp inal axis, and even remo vedfrom the bo dy, resp onded to the irritation ,

by peristaltic and rhythm icalm o vements o f the who le o rgan ,

even when only a po rtion o f it had beensubjected to the irritation . The kind o f irritant—electric ity

,heat, co ld,

mechanical irritation—made no difference. He also found that theuterus separated from the b ody, but maintained at its normal temperature spontaneously contrac ted and relaxed fo r about an hour afterthe death o f the an imal ; m echanical irritation increased the m o vementsObserved, narco tic s dim in ished them . Sim ilar rhythm ical m o vementswere, under like c ircumstances , Observed in the Fallo pian tubes . Dr.

Reimann c onc ludes that the c ontractions o f the uterus are under the

nfluencc of certain o rgans (ganglionic) , not yet anatomically demon

406 RE PORT ON MIDWIEERY , ETC.

strated, but which are situated in the uterus itself ; and that , like thec ontraction s o f the heart, they are independent o f the cerebro -spinalsystem

,though physio logical and patho logical facts pro ve that the latter

has certain influence o ver them .

O ser and Schlesinger rec ord the results o f numerous experiments todeterm ine the cause o f uterine m o vements . They exp erimented chieflyon pregnant rabbits, in which the uterus was generally at rest whenthey began their observation, and they found that whenever the blo odwhich c irculated either through the brain o r through the uterus itselfbecame extremely venous , tetan ic c ontraction o f the uterus to ok place .

The irritation o f the brain which produced uterine c ontractions wasc onducted down the Sp inal c o rd to the uterus

,and when the c ord was

divided irritation o f the brain from venous c ongestion produced no

effect . Stagnation o f blo od in the uterus, produced by c ompression o f

the aorta,caused uterine m o vements o f the same tetanic character. If

Spontaneous m o vements Of the uterus were present, they so on ceasedafter compress ion of the aorta was begun ; and when arterial blo od wasagain allowed to c irculate through the o rgan a strong c ontraction o f the

entire uterus,quickly fo llowed by rest, to ok place. Centralb . f. Med.

187 1 , and Brit .Med. June,Dr. Matthews Duncan writes (‘Dublin Quart. J May, 187 1)

on the efiicient p owers of p arturition . The first,and he believes the

best,results in the investigation o f this subject have been Obtained by

careful deduction fi om experiments on the tensile strength o f the

amn io tic membrane. He next o bserves that if, in an unobstructed andp owerful labour, the acc oucheur

,by the directly Oppo sing pressure o f

his hand on the foeta l head,arrests its progress for one o r several pain s ,

he has in the pressure by his hand, a force which, added to the smal lamount required to effect parturition , ,

exceeds all the combined powersOf labour in this case . Duncan, well accustomed to such work, findsby a ctual trial with an accurate dynamometer

,fifty pounds to be

about the highest power he can use situated at the bedside in attendan ce on a case Of labour . He believes that very few Of them o st powerful labours exert a fo rce of 50 lbs . , and that the great m aj ority Of

labours are acc omplished by repeated impulses , who se highest powerprobably never exceeds 2 5 lb s . He refers to the researches o f Dr.

Haughton (see ‘Retro spec t,’ 1869 who fo llows a different m ethodo f investigation from the above

,and measures the bulk and the extent

of the invo luntary and vo luntary muscles employed in the func tion .

Duncan comments on Haughton ’ s c onclusions . He do es no t say thatHaughto n is wrong in suppo sing that the uterus can exert a force of

54 lbs . , but he believes that only a very few diflicult labours require fo rtheir who le work a force exceeding 50 lbs . NO perinaeum wouldlong resist a force o f 50 lbs . repeatedly applied. He then furnishesarguments in favour Of the power o f the uterus in parturition as

c ompared with the powers o f the vo luntary musc les, which he believes render Haughton ’s c onclusion quite incredible that

,while the

power o f the uterus is 54 lbs ., that o f the vo luntary musc les can be

5 2 3 lbs . Haughton believes that on an emergency somewhat m ore

than a quarter o f a ton pressure can b e brought to bear upon a


podalic version in preference to the use of the forceps, and he c on

c ludes that the o peration o f p odalic version should always b e regarded,no t as one Of cho ice, but as one Of necessity . It is fraught withdanger to the infant and to the m o ther in all complicated cases ; itdemands great skill and experience fo r its execution ; numero us , andOften unexpected, difliculties are apt to be interpo sed, and yet the

time allo tted is exceedingly sho rt . The who le pro cess o f descent mustb e ac c omp lished in a few m inutes

,o r the ch ild, for who se benefit these

risks are incurred, will perish . Pro fesso r Ho dge mainta ins thathead-last labours simple tractile force sh ould not b e the so le recourse ofthe practitioner, but that flexio n o f the head should be insured and

m aintained. Amer. Journ . o f Med. July,187 I .)

Dr. Matthews Duncan c ontributes an elaborate paper on the curves ofthe develop ed genita l p ass age. Thefirst curve which he mentions is thatsaid to be at the brim o f the pelvis, with its c onvexity downwards andbackwards . He discusses the views Of Schatz and Schul tze on thispo int, and conc ludes that this curve do es no t exist . If it do es existwe must adm it that the advance o f the child’s head i s impeded, no to nly by friction and imperfec t dilatation , but that a new difliculty isintroduced to its transit, namely, the difference between driving a bodthro ugh a curved and a straight passage . If this curve be adm itted

]

,

the axis o f the genital passage, regarded in the antero -

p o sterior verticalplane

,has the Shape o f a Roman S ; but the autho r thinks that we are

nearer the truth in adopting the view that in this plane the genitalpassage has only one curve, having the c oncavity o f its axis lo okingforwards . T he second curve is also at the brim ,

and is indicated by thedeflection o f the uteru s from the mes ial line to the right o r to the left .The autho r gives the results Of some experiments made to c alculate theamount o f deflection ,

and he states that the angle of deviation Of the

axis Of the uterus from the axis Of the brim has important physio logical and practical bearings, though, as yet, but little wo rked o ut. The

m o st interesting applicatio n Of it is to assist in ac counting fo r the produc tio n o f face cases . T he third curve is the m o st extensive and bestknown . It is the great curve in the anterO-po sterio r vertical plane,which begins abo ve the m iddle o f the third bo ne o f the sacrum and

extends through the outlet o f the ligamento us pelvis to the o utlet fromthe so ft parts . In c onnection with this curve the sync litic and alliedm o vements o f the foetal head during its progress are to be studied.

The autho r shows that Schultze’ s recommendation to fac ilitate the

advan ce o f the foetal head after it has reached the flo or o f the pelvis byextension of the Sp ine (this extension he believes increasing the po sterior obliquity o f the axis Of the uterus

,and therefo re o f the fo rce Of

lab our as exerted o n this part) is founded upon what he (Dr. Duncan)regards a s a m isapprehension o f the c onditions of this curvature.

Med. Times and March 2,I 872 .)

Pro f. Trenho lme writes on irregular c ontractions of the uterus , andstates that in such cases he has found adhes ions existing between thedecidua and the uterine surface at term . He attributes the irregularcontraction to laceration o f the muscular fibres at the p o int Of adhesion, the parts lacerated acting as direct excitants of the spasm o f

ON THE MANAGEMENT or THE PERINZEUM. 409

the walls of the uterus . The treatment recommended is to pass thefinger and separate the united surfaces, but when they are beyondreach it is best to rupture the membranes . Hour-

glass and o ther irregular contrac tions after delivery are attributed to the same cause.

(‘Amer. Jo urn . May,M . Mattei, writing on false cramps during pregnancy and labour

,says

that they are to be explained by the pressure which the foetus exertson the course o f the nerve which borders on the painful part, thoughthe pressure bemade far from the seat Of pain . But these pains mayalso exist without pressure on the nerves, and may be a reflex phenomenon Of uterine trouble. Gaz . des Nov.

T achard writes o n the use of electric ity in m idwifery . He bel ievesthat uterine c ontractions canno t be induced by it unless they havealready c ommenced, and that uterine inertia com ing on during the expulsive stage Of labour is not to b e treated by electricity, but that inthe stage o f dilatation

,when applied to the lumbar region it increases

the contractions , bo th in duration and intensity. The cervix dil atesmore readily, the expulsion of the placenta immediately fo llows thechild

, and neither the mo ther nor the child suffers from the treatment .Dr. Chantreuil Speaks favo rably of uterine expression as a means Of

delivery. He bases his Observations on 540 cases in which the practicewas fo ll owed. Gaz . Me

’

d. de Paris,’ July,On the management of the p erincemn during labour.

—Dr . Go odell givesan elaborate historical account o f the practice, and Of the variousmethods employed. He co nc ludes that when it seem s necessary to aidnature the best metho d is to insert one o r two fingers of the left handinto the rectum

,the woman lying on her left side, with her knees well

drawn ’

up and separated by a pillow, and to ho ok up and pull fo rwardthe sphincter ani towards the :pubes . The thumb of the same handis to be placed up on the foetal head, scrupulously avo iding all contactwith the fourchette . T he right hand is to assist the thumb in makingthe head hug the pubes, o r in retarding its advance, and is to pressback the head from the perinaeum and thus to repress reflex uterineaction . By this metho d the perinaeum is brought forward without directpressure, and its dilatation is diffused o ver its entire surface. The aidrendered is no t liable to sudden interruption by any m o vements o f them o ther, and the c irculatio n o f the blo od is left free. Dr. G o odellbelieves that the rapid springing back o f the fo urchette o ver the projecting no se

,o r the subsequent rapid expul sion Of the shoulder Often

pro duces lacerations . These are also well contro lled by the abo vemethod, in the former instance, by merely pulling forward the sphincterani, in the latter by adding the suppo rt Of the right hand to the emergingshoulders . Amer . Jour . Med. Jan .

Dr. Swayne states Brit . Med. J July,1872 ) that his expe

rience pro ves the inefliciency o f suppo rt for the prevention o f perineallacerations . There is seldom any great danger o f rupture untilthe head is pro truded so far that the ac coucheur can grasp theexpo sed po rtion with his thumb and fingers . When this can be donethe best plan is to press the head forwards as much as po ssible under

410 REPORT ON MIDWIFERY , E TC .

the pubic arch, SO as to prevent the vis a tergo from acting so directlydownwards upon the perinaeum . Wh en rupture takes place the rentusually commences at the fourchette and extends backwards

,but

sometimes it begins near the centre of the perinaeum and extendsfo rwards . He believes that the m o st frequent cause o f laceration is anunusual breadth o f the perinaeum .

Dr . Aveling has c o llected the histo ry Of fo rty-four cases Of p ostmortem p arturition, and deduces the fo llowing co nc lusions . E xpulsiono f the c ontents o f the uterus may take p lace after death without theaid o f art. This may o c cur in cases in which no symptom o f naturalparturition existed before death . Sp ontaneous evo lution o f the foetus

,

and pro lapsus, inversion, and rupture o f the uterus may o c cur po stmortem . These phenomena are explained either by the c ontractingpower which persists in the uterus after the death o f the rest Of thebody

,or (and this is the m ore frequent cause) by the pressure exerted

upon the uterus by gases o f decompo sition pent up in the abdomen .

A child may c ontinue to live in the uterus for many hours after thedeath o f its mo ther. Obst .

Deformities of the Pelvis , and Dystocia by theMother .

Prof. O . Sp iegelberg gives (‘Archiv f. 11,I,187 1) an

elaborate report o f two cases o f obliquely distorted pelvi s . The firstc ase was that o f a woman who had sustained a fracture o f the righttibia in its lower half when three years o ld. The pelvi s was contractedon the right side, and there was syn o sto sis o f the right sacrO-iliac j o int

,

and considerable sho rten ing o f the right lower limb . Premature labourwas artificially induced in the thirty-fifth week o f pregnancy . The

sec ond case is described as one o f inflammation o f the right sacro -ilia cjo int and secondary atrophy Of the surrounding bones without sync sto sis . Delivery by perfo ration and cephalo tripsy . Discussing the

etio logy, he states the two chief causes to be the ino rdinate pressure on

one half o f the pelvis and the one-sided atrophy o f the bones enteringinto the sacro -iliac j o int . E ither Of these factors may be the primaryone .

Dr . Harris describes Amer. Journ . of Nov. 187 1) theusual form s of pelvic deformities, and illustrates his paper by severaltypical examples .Petit relates a case o f oblique-o vate pelvis , in which the labour wasquite natural . The child was o f medium Size. The brim o f the pelvis

,

c ontracted on the left, was 1 23 centimetres (about 5 inches) in itsgreatest Oblique diameter, from the right ilio -pectineal em inence to theleft sacro -iliac synchondro sis, and 9 centimetres (a little o ver 33 inches)in the sho rt Oblique diameter, from the left iliO-pectineal emmence to

the left sacro -iliac syn chondro sis . The distance from the sacrovertebral angle to the left ilio -pectineal em inence was 6 centimetres

,

and to the right n ine and a half. Bull . Med. da N o rd,

’Feb .

E rnst Braun writes Arch . f. iii,I ) on a case o f funnel

shaped pelvis .


twin foetal heads in the pelvis . The patient was seizedwith convulsions

,and the attendant applied fo rceps to

head and delivered it eas ily. T he Shoulders did n o t

exam ination a second head was found in the pelvis . Whearrived he appliedchild then fo llowedthat the delivery by fo rceps did no t cause the difficulty, asonly case o f the kind he has found recorded in which thewas delivered artific ially . Probably a capac ious pelvis hasinfluence in the production of the ac c ident .The delivery o f a dicephalous m onster is described by Wettengel.Amer. Journ . Nov.

Dr . Po rter relates a case of suc cessful reduction Of pro lapsed funisby the po stural metho d. The po sition he rec ommends is on the knees

,

with the chest and face resting on the bed. Amer. Journ . o f Med.

Jan .

Cases o f quadruplets are recorded by Leopo ld Arch . f. II,

2 , by Lowndes Brit . Med. Feb . and by Cuppaéridge (‘Dub l . J March ,

Obstetric Op erations .

Caesarean section—This operation was performed by Mr . Gibbons ona woman,

set. 2 2 , and who was three feet ten inches in height . U teruscontracted rapidly ; no sutures were applied to the uterine wound.

Uncontro llable vomiting commenced so on after, and continued till death,forty hours after the Operation . NO peritonitis

,no extravasation .

Antero -po sterio r diameter at brim an inch and three quarters . Transverse diameter inches . Obst .In a case reported by Dr . Inglis (‘E din . Med. J 187 1) the

abdominal incision was made on one side Of the median line, s o as to

avo id inc ising the expanded central tendon between the rec ti,which is

to o m obile to be afterwards kept in appo sition ; and the uterine inc isionwas c ommenced an inch and a half to the left o f the mesial line, and wa scarried first downwards and then to the side, the curve o f the inc isioncorresponding with the direction o f the outer c ircle o f fibres surro undingthe left c ornu . The object o f this was to avo id cutting acro s s m ore

muscular tissue than was necessary. He doubts the advisability o finserting sutures into the uterine wall .Dr. Harris reco rds Amer. Journ . o f 1871

- 2 ) sixty cases o fthe Caesarean section in America . Of these, thirty-two were succes sfulas regards the mo ther, and twenty-seven o f the children were saved.

One hundred and six cases are quo ted from Great Britain and Ireland,

eighty-eight of which were fatal to the mo ther,while Sixty o f the

children were saved.

Dr. Andrei c ompares (‘Western Lancet,’ 1 872 ) the result to m o therand child in a large number o f cases, the summary of which he

has c o llected, o f premature labour, symphyseo tomy, and Caesareansec tion .

M . D’

Olier performed the Caesarean section on account o f a sacral

OBSTETRIC OPERATIONS. 4l3

successful result to the mo theracting the child to eversion o f theuterine sutures were employed

,

also a successful case fo r pelvic

2 ) a case Of Caesareanthe rickety type, the antero o sterior dia

half. After extracting the c ild alive thewo und were brought together by interrupted

sutures,but no sutures were inserted through the uterine walls . The

patient lived six days . The uterine wound measured one inch and a

half ; it was open,and there was a small quantity o f dark co loured blo o d

in the pelvis . The intestines and their peritoneal c overing werehealthy, but the peritoneum investing the po sterio r part o f the pelviswas inflamed.

A successful case Of Caesarean section is recorded by Causse LyonJuly, The m o ther was thirty-two years Old

,rachitic , and

the sacro -pubic diameter measured O '

O67 m ill imetres . The child also wasextracted alive and survived.

Dr. Ho scheck performed the Caesarean section upon a patient whodied from phthisis, near the full term o f her pregnancy . The operationto ok place ab out ten m inutes after death

,and although the ch ild was

apparently dead when extracted, insufflation from m outh to m outhrestored it. (

‘Archiv f. 11,I,

M o linier also relates Gaz . des lxxxi,187 1) a case o f po st

m ortem Caesarean section ,in which the child was saved.

On decap itation as a mode of delivery in cases of shoulder p resentation,in which version canno t be safely ef ected.

—Dr . G . H . Kidd (‘DublinQuart . J May, 187 1) writes on this subject . He describes threec onditions in which version canno t be performed witho ut expo sing themo ther to danger . These three c onditions are respectively met with ;I . In tho se cases where the shoulder is s o far advanced into the pelvis,and the action o f the uterus is

,at the same time

,so strong that it i s

impo ss ible to raise or m ove the child. 2 . In cases where the difficultyarises from the firm c ontraction o f the uterus, the liquor amn i i i sevacuated before dilatation Of the OS uteri has taken place

,and the

uterus becomes m oulded to the child’s b ody. It is, in these cases , quitep o ssible to intro duce the hand, seize a fo o t and bring it down into thevagina ; but the child do es n o t turn ,

the head remains fixed in the iliacfo ssa , and the uterus m ay b e to rn in the effo rts to c omplete the delivery.

3 . In cases Of tran sverse presentation with extreme narrowing o f the

pelvis . Dr. Kidd describes the various instruments which have beenused for decap itation,

and espec ially a plan ado pted by Prof.Heyerdahl,

and practised in a m o dified fo rm by Paj o t and Tarn ier. The instrumentc onsists Of a handle and a ho ll ow stem ,

with a strong wire in its centre ;and after it has been passed round the neck the internal wire is pushedupwards , and a lo op o f string can now be passed round a knob p lacedat the end o f the wire. A co rd is thus left round the neck, by means Ofwhich a chain o r wire rope is drawn round, and with this the neck issawn through . Dr . Kidd suggests that the operation may be much

414 REPORT ON MIDWIEERY , ETC.

simplified, as the co rd m ight be very easily carried round theneck by means o f an elastic catheter m ounted on [a firm styletuterine sound. The

has been passed round

drawn back with it . Thspeculum,

the catheterdivided. T he Operationfo r dividing the neck, bytion by breaking of the

injuring the soft parts 0that it would be best to sto as so on as the spinal co lumnand to leave the head attac ed to the b ody by a portiontissues o f the neck . It is Obvious that the division o f

co lumn would do away with the difficulty o f turning, andattached to the head woul d fac ilitate extraction .

Drs . Affleck andMacdonald relate E din . Med. J July,187 1 ) a

case o f shoulder presentation in which turn ing was im o ssible, and de

capitation was impracticable, owing to.

the po sition 0 the foetus withthe head very high up and the narrowness o f the inl et of the pelvis ;they

,therefo re, resorted to spondylo tomy . The thorax having been

Opened by long vaginal scissors , two fingers were introduced, so as to

push aside the c ontents Of the chest and feel for the vertebral co lumn .

T he Spine was then clipped through without any great difliculty. Tra ction was then resumed o n the fo o t, which had originally been broughtdown, and this time with c omplete suc cess . An Old prac titioner

,in

the same journal (O ct . prefers to spondylo tomy o r decapitationthe remo val of the presenting arm ,

and also Of the o ther arm . He saysthat the increase o f space affo rded by the remo val o f the two little fatarm s is very great , and the shoulders being removed from the chestgreatly increases the facil ity o f turning . He has practised this methodon several o ccasions .Mr . F . W. Wright recommends Brit . Med. J O ct. 187 1) a

method o f bisec ting the foetus in utero in arm presentation ,in which

version is impracticable. The presenting member i s to be seized withthe right hand, and, while considerable trac tion is employed, the left handis to b e introduced into the vagina and kept firm ly upon the child’s neck .

A blunt b o ok with a curve suffic iently large to embrace the neck, and

having a perforation at the extrem ity o f the curve,is armedwith a piece

Of tape and made to embrace the neck . A leash o f ab out a do zen verythin wires , about a yard long, twisted together at the ends, should betied to the end o f the tape. By pull ing at the tape the wires will bedrawn o ver the child’s neck, and with a saw-like mo tion Of the wiresthe head may b e cut Off in five seconds .Dr. Tucker, o f Bermuda

,describes a method o f delivery in cases Of

arm presentation,after the usual m ode o f turning has fa iled. He

places the patient as for litho tomy, perforates the bo dy o f the child,and empties the abdomen and thorax suffic iently to enable him to

reach the bodies o f the foetal spine. He then c rushes these with a

strong fo rceps . Bending o f the child’s bo dy then takes p lace, and

it descends sufficiently low to enable a handkerchief to be pas sed


the appliances used for mechanical dilatation o f the cervix uteri . He

compares the b ougie, the tangle-tent, the sponge-tent, and the indiarubber bag, in reference to the amount o f fo rce exerc ised, the amo unto f expansion pro duced, and the am ount o f time required fo r produc ingthe expansion . In using great force to pass a common uterine probethe instrument is bent , and by experiment the force required to bendit is found to b e about fo ur po unds exerted at its po int, thejhandl e beingfixed. With the same force used the tension o verc ome will b e thegreater in proportion as the wedge is sharper or has a smaller angle.

Assum ing the surface pressed upon in the cervix to b e one tenth o f aninch in breadth , then the dilating fo rce exertedwill b e about n ine lbs . , ifthe wedge have an angle o f 90 degrees , or 90 lbs . on the square inch , andabout eighteen lbs . if the wedge have an angle o f 45 degrees , o r 180 lbs .on the square inch . The tangle-tent was found experimentally to havean expanding fo rce o f 500 lbs . on the square inch , the sponge-tent afo rce o f only from 2 0 to 30 lbs . , and the india-rubber bag a fo rce from15 to 2 5 lbs . on the square inch . The amount of dilatation pro ducedby the o rdinary series o f surgical bougies successfully used is abo ut aquarter o fan inch . A tangle-tent who se stem is about one fifth Of an inchin diameter expands to o ne half an inch if no t subjec ted to pressure,but in pro portion as the resistance to b e o vercome increases s o do esthe amount o f ac tual expansion decrease. A smal l sponge-tent m o re

than trebles its diameter when not under any c onstraint ; its expansion ,

however, under slight c ompression i s very small indeed. The expan

sion produced by the india-rubber bag is practical] un lim ited,because

any bag can be easily withdrawn,and ano ther o t

ylarger size immediately substituted fo r it . N0 time is lo st in bringing the full power o f

the bougie into action . The tangle-tent expands very slowly ; befo reits small dimensions have doubled twelve hours will have elapsed. T he

sponge-tent rapidly expands when unconstrained ; and n o time is lo s tin bringing into ac tion the full power o f the india—rubber bag, and itsp ower continues till its full expansion .

Accidents during Labour.

Rup ture.—Fo urrier reco rds a case o f rupture o f the uterus with

escape o f the foetus and placenta into the abdom inal cavity,in 'which

he perfo rmed gastro tomy on the fifth day. The patient was 2 9 yearso f age, the m o ther o f two children . Six weeks befo re her expec tedlabour she fell in go ing down stairs ; this , however, gave rise at the

time and fo r a few days afterwards to only slight abdom inal pains .Labour came on at term ,

and so on after the rupture o f the membranesshe felt sudden and severe pain

,and there was cessation o f labour

pains . On careful exam ination four days afterwards, the abdomen presented two tumours ; the one on the right was made up o f the foetus,while that on the left was about the size Of the uterus so on afterlabour. An inc is ion was made on the right, the foetus with its mem

branes and the p lacenta were extracted, and, although the patient afterwards presented some indications o f purulent infec tion,

she ultimate lyrecovered. Fourrier calls attention to the absence of any severe hae

ACCIDENTS DURING LABOUR. 417

mo rrhage, only a slight sanguineous discharge appeared externally eighthours after the rupture. The presence of the foetus in the abdominalcavity did no t give rise to general peritonitis . He believes that the fallwas an important element in the production Of the rupture ; it probably produced a c ontusion o f the uterus wh ich led to thinning o f theuterine walls . Bull . de Aug.

Prof. Dohrn writes Arch . f. iii,i) on a case o f ruptured

uterus in the first stage o f lab our. Rickety pelvis,no degeneration o f

uterine tissue . Cessation of foetal heart sounds early in labour.

Rupture o f the uterus is also illustrated by Clements Brit . Med.

O ct . Whinery (‘Philad. March, and

Mordhorst (‘Deutsche No s . 1 7, 18,Mr . Jamieson relates E din . Med. J Sept . 1872 ) a case o f

rupture, unattended at the time o f its o c currence by anyserious symptom s . The child was b orn by aid o f the fo rcep s, dead.

At the po st-mo rtem examination the pelvis was found to b e in everyrespect no rmal, but there was an acute curvature o f the spine in thelower do rsal region the spine was SO sho rtened that the last ribs wereo n a lower level than the crest o f the ilium . The anteversion o f the

uterus was very great, and it therefore ac ted at a great m echanicaldisadvantage , but, continuing to c ontract vio lently, to re itself from itsvaginal attachments .Four cases o f uretero -uterine fi stula are rec orded in the

‘Bo s tonJournal, ’ Jan . 1 872 . E ach case succeeded to a difficult labour, andwas characterised by an alm o st uninterrupted flow o f urine from the

OS uteri, with c omplete c ontinence Of urine in the bladder.Dr. Argles relates the case of a prim ipara, in which the foetal head

passed through the po sterio r wall o f the vagina, and the face presentedthrough an artificial o pening in the perinaeum , just anterior to the anus,and w ithout injuring the bowel . Dr . Argles passed a director downthe natural passage, between it and the child’s head

,and slit it up for

an inch and a half. The wound entirely healed, and the patient wasable to walk down stairs in three weeks . Lancet,’ April,Invers ion—Dr. White c ontributes two additional c ases of inversion

o f the uterus , comp leting a series o f nine cases,all o f which have been

reduced by manipulation by a single effort . One case was o f fifteenyears duration . In recent cases the fundus can be pressed into thebody andneck

,o r dimpled as it is termed, by pressure upon the m o st

depending part . In chronic cases Dr. White uses the left hand o verthe pubes, the fingers pressing on the anterior wall Of the uterus andassisting in pulling open the uterine cavity . T he right hand enc lo sesin the vagina the entire uterus, and pressure is made against the fundusby a wo oden or hard-rubber enlarged extrem ity o f the repo sitor, thedistal extremity o f the stem being made into a screw s o as to fasteninto a c o il of steel spring wire, requiring eight or ten pounds pressureby the breast Of the operator, against which it is p laced, to bring itdown . Amer . Journ . Med. April ,Fo ur cases o f invers ion of the uterus are recorded by Dr. Braxton

Hicks . Restoration was effected in each case, in one case a week after

lab our. He wonders why any doubt has been expressed that remo val Of27


cases (ibid. ,Aug. 1872 ) Dr. Hicks

bags into the vagina, which shouldis a ring-shaped one, pressing onand steadies the uterus under thea glo bular one

,

through the ringshould be given

Into thebe screwed,the b ag at

storation is effected thecavity o f the uterus . Ittwelve hours to lessen the irritability Of the uterus .A case o f inversion o f the uterus with no perceptible sho cklittle haemo rrhage. Dr . Bell Lancet

,

’Sept .

Dr . Wo o dward relates Amer. Journ . o f Med. 187 1) a case o f

sp ontaneous inversion of the uterus in a prim ipara . T he placenta wasshed natural ly, but severe po st-partum haemo rrhage supervened the

handwas intro duced, andwhen the patient was left, the uteruswas normalin po sition . Next m o rning, c ontrary to advice, she was allowed to getup and sit on the commode ; severe haem o rrhage came on, and the uteruswas found inverted. This was resto red, but the patient died withsymptom s o f thrombo sis .Dr. !Taylor contributes an elaborate article on the mechanism of

spontaneo us active uterine inversion . New Y ork J May,

A case Of inversion came under the care o f Dr. Hall Davis tenmonths after labour. Ordinary effo rts at reduction failed

,and, the pa

tient being to o weak for°

Sustained pressure during c ons ecutive days,the uterus was remo ved by the single wire écraseur. Discharged on

the thirty-third day . O bstet .A case o f emp hysema during labour is related by Dr. Whitney Bo s

ton J Nov. 30 , The patient was a ro bust young woman,in her first labour, which was very severe and pro trac ted. The irruption Of air to ok place in the night, and was m omentarily attended withsome difficulty Of breathing ; it was s o extensive as to nearly o r quitec lo se the eyes, reaching to al l parts abo ve the waist, where it wasarrested in its downward progress by the tightness o f the clo thes . The

attendant assured his patient and her friends that it woul d sponta

neously disappear in a few days , and this prediction was fully verified.

Whitney refers to Cazeaux’s wo rk,which c ontains a chapter on pul

monary and subcutaneous emphysema, and in which cases such as theabo ve are stated to be m o re rare than tho se in which the air Spreads tothe face and neck only

,and may o ccasion o ppression and threaten suf

fo cation . A case pro ving fatal in fo rty-six hours after delivery hasbeen recorded by Depaul, where the air diffused itself through the in

420 REPORT ON MIDe ERY , E TC .

with a tube pro ceeding from it on each side, terminated by a stopco ck,is filled with water and c onnected with the silver tubes . The c o cks arethen turned straight, and the o peration c ommenced by compressing theindia rubber on the efferent side and squeezing the bulb . This fo rc estwo drachm s Of water into the afferent vein . T he afferent tube is thenc ompressed and the bulb allowed to expand slowly,when blo od will b edrawn into it by the efferent vein . By repeating this pro cess anyquantity Of blo od can ,

at any rate,b e transmitted.

Dr. Richardson stated at a meeting Of the London Medical So cietyLancet, ’ Feb . 187 1) that the details o f the Operation o f transfusio n

had reference to the needle, the knife, and the passage o f fluid into theveins . The needle he rec ommended i s curved, probe po inted, and withan o pening in the under side at the tOp , curved s o that when introduced into the vein , if the end is held down, the apex applies itself tothe upper wall o f the vein,

whilst the under side o f the needle is freeand allows the blo od to escape . As to the knife

,it should b e one to

enter the vein at once,having a small blade with a cutting edge along

the entire o f o ne side, and only fo r about o ne eighth o f an inch on theo ther. AS to the pas sage o ffluid, al l syringes are bad. The mere ele

vation o f the vessel containing the blo o d abo ve the patient is suffi c ient .He uses a ves sel c onstricted at the base and then widened out gradu

ally to the to p . At the constricted part a wet valve is fo rmed by aflo ating ball when the vessel c ontains fluid, and this fluid gets low in thevessel . At the lo west part o f the vessel is an arm attached to a tube

,

and this tube is c onnected with the needle, the fluid from the vesselfinding its way along the tube to the needle.

Dr. Higginson c o ntributes a repo rt o f thirteen cases o f transfusion .

The average quantity o f blo od injec ted was nine o unces, the largestquantity was twenty o unces , and the smallest four ounces . NO sub

stance was m ixed with the blo od, and it was n o t subjec ted to any manipulation . Ten o f the cases o ccurred in o bstetric practice, and fo ur o fthese recovered. (

‘Liverpo o l Med. Surg. A suc cessfulcase Of transfusion is reco rded by Dr . Ringland. Dub . J Jan .

1872 )Dupierris publishes twenty-four cases Of p o st-partum haemo rrhagetreated by the injection o f a so lution o f iodine into the uterus, all witha successful issue and no ac c ident . Bulletin de

Dr. Bo o th also writes on injec tion o f iodine in po st-partum haemor

rhage. (‘Virginia Record, ’ Dec .

Therap eutics . Monteverdi records Gaz . Med. de Paris,

’

NO .

the resul ts o f various experiments madequinine on the uterus . He invariably usedthis substance exerc ised a general ton ic inflb ut espec ially o n the uterus . About halftio n it produced slight contractions o f the

THE PUERPERAL STATE . 421

mo ther or the child, its action is certain, the contractions it induces areregular and natural, and it is free from danger at whatever periodo f pregnancy it is administered. See also Delioux de Savignac, Bull .Gén. de vo l . 81 .

Dr. Denham c onc ludes that ergo t of rye does no t act as a po ison on

the foetus . Physio logical experiments on animals are in favour o f theview that ergo t is , at all events, n o t a powerful o r vio lent po ison . He

believes that when ergo t is administered between the sixth and ninthm onths the life neither o f mo ther n or child is affected, and that labouris no t induced by it until the full period o f utero -gestation is c ompleted. Dub . Obst .Dr. Thompson believes that ergo t Sho uld be administered with great

care i

ppersons o f feeble cardiac power. Brit . Med. J Aug.

1872 .

IV .

—THE PUE RPERAL STATE .

Professo r Martin adheres to the view previously put fo rward by himas to the nature o f p uerp era lfever, that it is due to a diphtheritic process set up in the female genitalia, this diphtheritis spreading by aninfiltration o f the pelvic cellular tissue

,o c cas ionally by extensio n along

the muc ous membrane direct to the peritoneum , o r more frequentlythrough the lymphatic s . In reference to the influence of retaineddecompo sed po rtions Of placenta in setting up puerperal fever he po ints outthat fragments are frequently retained in utero without setting up anydecompo sition o r putrid abso rption ,

s o that in the fo rmer cases some

o ther inc ident must b e sought to explain the o c currence . He thinks apreceding inflammation of the gen italia, as seen in severa l c ases ofgono rrhoea before labo ur, has some influence in pro duc ing the diphtheritic condition after lab our ; although , as a rule, the po ison gainsaccess in o ther

,and very different ways . Martin po ints o ut that

diphtheritic affection Of the genitals do es no t exc lusively attack lyingin women, although they are particularly subject to it . Dubo is“observed that at the tim e when puerperal fever was epidem ic

,the

young m idwives o f the Maternité were o c casionally, during menstruation

,attacked with a febrile affection analogous to that affecting the

women whom they attended. In reference to the treatment, theprophylactic measures are the m o st important, but digitalis , quinine, andbaths are indicated for the fever, while disinfectant vaginal and uterineinject

)

ions are insisted upon . (‘Alleg. Mediz . Aug. 9 and I 2

,

I 87L

The patho logy Of puerperal fever is discussed by Omb oni . Gazz .2 5 , 2 6,

Dr. Waldeyer,o f Breslau

,writes Arch . f. iii

,2 ) on the

o ccurrence Of Bacteria in the diphtheritic form o f puerperal fever.

After referring to the lab ours o f Mayrho fer, Haussmann , Co ze, andFeltz , in the same direction ,

he states that he has examined the diphtheritic dep o sit on the inner surface o f the uterus, the purifo rm m assesin the lymphatic vessels Of the uterus and o f the bro ad ligaments

,the

peritoneal exudation (bo th the fluid exudation and the yellowish -whitepurulent fibrinous flakes) , and in one case the thick exudation in the

422 RE PORT ON MIDWIEERY , E TC .

pleural cavities and pericardium . In all these he has fo und bacteriain a remarkably large quantity. In the diphtheritic patches they liebetween the pus -cells and tho se o f the partly m ortified tissue elements .The purifo rm c ontents o f the lymph channels c onsist o f pus -co rpusclesand (in large pro po rtion) of bacteria , and these latter are also to b efoun d in the peritoneal flakes , m ixed with pus-c o rpu sc les, young cells

,

and fibrine masses . In the last case, on which Waldeyer bases hisObservations , the po st-mo rtem exam ination was made six hours afterdeath, the body was yet warm ,

and. n owhere were there any indicationsof dec ompo sition to b e observed in the o rgans . The o ccurrence in al l

the cases o f bacteria within the pus-c o rpuscles is very no teworthy .

Waldeyer believes that the changes o riginate on the inner surface o f

the genital canal, and creep upwards along the lymphatics to the peritoneum . An exudative purulent inflammation o f the abdom inal parieteso c curs, which quickly extends to the diaphragm ; and then we find

inflammation o f the diaphragm , and still further pleuriti s and pericarditis .Contribution to the Study of P uerp eral Sep ticaemia .

—The fo llowing i sthe summary Of the c onc lusions arrived at by M . d

’

E spine in his longand elabo rate articles on this important subject, recently published inthe ‘Archives G énérales de Médec ine .

’I . Puerperal septicsemia fc on

sists o f a series o f symptom s , the gravity o f which is in direc t relationto the quantity o f septic matter absorbed by breaches o f surface in theutero -vaginal canal . 2 . These symptoms are no t peculiar to the puerperal state, and ought to be c lassed with tho se pro duced by septicaemiaIn the wounded and in animals . 3 . The so urce o f puerperal septicaemiai s always the uterus o r vagina ; and al l causes which prevent the healing Of the bared interio r o f the uterus , o r which favour the produc tionof septic matter in its neighbo urho od, have an impo rtant ac tion in itspro duction . 4 . T he mo st c ommon channel o f absorption is throughthe lymphatics, and its passage through them can generally, but no t

always,be traced by lymphangitis . 5 . Peritonitis is the result o f the

conveyance of septic matter through the lymphatics o f the uterus, andit may be c ompared to the lo cal inflammatl ons which develo p round

infected wounds . 6 . The effect o f septic abso rption i s to develop c ongestions and inflammations in internal organ s, chiefly in the lungs,k idneys , and intestines ; subserous ec chym o ses and interstitial apoplexy ; internal and external inflammations , which lo calise themselvesin the neighbourho od o f the serous membranes ; during life, theseactions are recognised by fever, diarrhoea, pulmonary c ongestion

,ep is

taxis,and o ften by fugitive cutaneous erup tions . 7 . Milk fever has no

existence ; febrile action in the first week after delivery almo st alwaysdepends on absorption Of lo ch ia through Slight abrasions o r lacerationso f the utero -vaginal canal . It may continue for some weeks shouldthe uterus no t b e firm ly co ntracted, o r should the lo chia be foetid. In

the latter case ulcerations , through which absorption takes place, m ayalm o st always be found either on the cervix o r in the vagina . 8. Theses lighter affections are Often,

but no t always,accompanied by angio leu

citis and slight perimetritis . When the septic po ison c ontinues longWe mayhave consumption anddeath (phthisic sep tigue) . 9. Puerperal

424 REPORT ON MIDWIPERY , ETC .

P uerp eral Convulsions—Halbertsma writes Med. ix

,2 7,

1 87 1) on the etio logy o f ec lampsia . Veratrum viride in large do ses isrecommended as a sub stitute fo r blo odletting in puerperal c onvuls ionsAmer. Journ . o f Ob stetr,

’

Cases o f puerperal ec lamp siatreated by venesec tion are reco rded by Swayne Brit . Med. JFeb . and by Jones (ibid. , April, A

‘

case Of puerperalc onvulsions successfully treated by chlo ro form ,

Ro ss Lancet,’ Aug.

Puerperal c onvulsions treated by hydrate o f chloral Furley(‘E din . Med. J Nov . Geikie (‘Canada Lancet, March ,187 1) Starley (‘Am eric . Practit ,

’187 1) Ferris Brit .Med. J

April,

Two cases suc cessfully treated by chlo ro form are recordedin detail by Dr. E . R. Townsend. In one o f the cases there was smartuterine haem orrhage after delivery, but the bleeding had no effect whateven in contro lling the convulsive attacks (‘Dublin Quart. JFeb . Dr . Whidb orne advises the use o f suppositories of

chloral hydrate, when that drug canno t be taken by the mouth .

Lancet,’ June,A case o f sudden death seventeen days after delivery is reco rded(‘Obst . 187 1) by Dr. Playfair. A slight p leuritic attacksucceeded labour, and death probably resulted from embo lism . T he

inflammatory c omplication had apparently produced an increasedhyperino sis o f the blo o d ab ove that already existing ; and hence inflammatory affections in the puerperal state should b e regarded with a

greater susp icio n and anxiety than at o ther times .A case o f sudden death seventeen days after delivery was related b

Dr. Ringland to the Dublin Obst . So c . The heart was found small:soft

,and flabby

,w ith much fat depo sited

°

externally . The pulmonaryartery and its two branches were filled with a large tho ugh soft c lo t .

ghe

d

u

te

rine walls were so thin, as almo st to resemble the urinary

lad er .

Dr. Madden c ontributes a series o f cases o f sudden death so on afterparturition . Amer. Journ .

M r. Bassett relates thirteen cases o f secondary hwmorrhage com ingon between the third and the thirty-second day after delivery . Fivewere due to the irregular and ineffic ient c ontrac tion o f the womb , withc lo ts in its interio r ; in fo ur cases the haemo rrhage aro se from a retained

p o rtion o f placenta ; and the remain ing cases were due to retainedportion o f membrane, fibrous po lypus

,inversion o f the uterus , and

imperfect invo lution . Brit . Med. J Aug.

Dr. Jenks exhibited to the Philadelphiamen Of p la centa succentwria ta , which b adafter the delivery o f the child and o f thadherent to the uterus

,and had evidentl

umbilical c ord by a delicate funrise to a c onstant haem orrhage .

From a careful m icro scopl cal exam ination Of an enlarged, imperfectlyInvo luted uterus, Dr. Snow Beck conc ludes that the enlargement ism ore due to the increased size and amount Of the soft tissue ” o f theuterus than to the increased Size o f the contractile fibre-cells . Althoughthe blo od-vessels are loaded with fluid blo od there is no evidence of the

THE INFANT. 425

existence of inflammation . This exp la ins the frequent haemo rrhagesno ticed in such ca ses . Any lo cal application to be o f value shouldbe applied to the entire uterine cavity

,as the chief seat o f the abuor~

mal state is the body o f the uterus . Obst .

V .—THE INFANT .

Dr. J . Gregory Arch . fur 11,I, after relatingseveral Observatio ns o n the weight of infants , c onc ludes that- (I ) All

children decrease in weight during the first few days after birth . (2 )They begin to lo se in weight during the first hours Of extra-uterine life .

(3) The duration Of the decrease is generally two days in healthy,

full-time children , bro ught up at the breast . (4) In children broughtup by hand and in the premature the dura tion o f the decreaseis from half a day to a day, and from two to three days longer. 5 )Ful l-time children brought up at the breast increase in weight afterthis directly and to lerably regularly, and generally attain at the end o fthe seventh day to their o riginal weight . (6) Immature childrennourished by the breast have a varying increase, and even on the eighthday usually only make up half their sustained lo ss . (7) There is generally no actual increase in the first eight days in children brough t upby hand. Since the lo ss is c ontinually in greater propo rtion ,

they lo sein weight, therefo re, also after the beginn ing o f the first increase . Thisapplies to the premature children in this catego ry in a greater degreethan to the mature ones . (8) Nutrition is m o re active in boys than ingirls, whence it fo llows that boys begin to increase c omparativelyearlier, and that m ore per cent . o f boys than Of girls in a sim ilar perio dexceed their o riginal weight . (9) There is no relation between the

falling o ff o f the navel string and the c ommencement Of the increase inweight . ( 10) N ourishing supp ort to the lying-in woman has a favorable reaction On the child, shortening the perio d of lo ss o f weight, and

rendering the in crease m o re regular and greater.

Wernich , from o bservations founded on 1889 births confirm s thestatements o fHecker and Duncan , and says- (I ) That the weight o f

the foetus increases with the age o f the mo ther till she has attained theage o f thirty-three, and that the length o f the foetus increases up tothe forty-fourth year. (2 ) E ach new infant outweighs and is largerthan the preceding one . (3) Long intervals between the pregnanc iesare m ore favorable than sho rt ones . (4) Women who have menstru

ated early are confined fo r the first time o f a m o re vigo rous child thantho se in whom menstruation was late in appearing. Gaz . Med. de

Strasbourg,’ O ct.Stil lbo rn infants (an epistle direc ted to Dr. C . Ludwig, by Dr.

Schultze, Jena , —The c ondition o f a stillbo rn infant is, acco rd

ing to Dr. Schultze, in all cases one Of asphyxia . T he stillbo rn sometimespresent an anaemic , and at o thers an apop lectic c ondition ,

but under bo thc onditions the still birth is one Of actual asphyxia . The mass o f blo od

,

in the o ne instance, is insuffic ient to enable it to take up and conveyan adequate amount Of o xygen to the medulla oblongata, the exc itability o f which is, in consequence, reduced, and finally extinguished.

REPORT ON MIDWIFERY , E TC .

On the o ther hand, the apoplectic fo rm o f asphyxia is when the medullaoblongata is not in a c ondition to respond to the no rmal exc itors presented to it . T he fo llowing is the author’ s general statement o f thefour patho logical c ondition s, into one o r o ther Of which stillbo rn chil .dren are distributable A so greatly dim inished exc itability of

the medulla o blongata that, under the no rmal exc itants, the propernervous influence from it is no longer transm itted to the res iratoryapparatus , hence there necessarily results a deficient supply o l

poxygen

to the blo od . (2 ) A defic ient o xygenation o f the blo o d,and its neces

sary c oncom itant, an abno rmal ac cumul ation o f carbon in the blo od.

3) Constant lessening in the fo rce o f the circulation from the slownesso f the heart’s c ontractions, and the immediate and sec ondary c ousequen ces, causing what may, in some sense, be considered as a c om

pensato ry m o vement, besides overfilling the heart with blo od, directingthe flow of the latter towards the thorax . (4) The c logging up , to a

greater o r less extent , Of the trachea with liquor amnii,mec onium

,

slime , and blo od. T o arouse the suspended vitality of the stillbo rn whofall within thefir s t propo sition presents three indications z—T O increasethe excitation o f the medulla, so that the respirato ry nerves Shall reac tto endeavour, by acting upon the peripheral nerves , to exc ite the actiono f the respirato ry muscles ; o r to endeavour to reinstate the no rmal exc itability of the medulla . In the cases embraced in the second pro po sition

,there is a defic iency Of oxygen . N ow

,after b irth this defic iency

can be supplied only through the lungs, and hence, in the absence of

natural respiration, an attempt must b e made to imitate it artific ially .

In reference to the cases o f stil lbirth embraced by the third pro po sition

,it may be understo od that when the infant is bo rn deeply asphyxi

ated,with very slight action o f the heart, while the blo od in the capii

laries o f the lungs is almo st stagnant, how little o f the c irculating mas scan, by artific ial inflation o f the lungs , be bro ught into contac t witho xygen . Hence the increased action o f the heart c aused by such mean sis onl y o f tem po rary c ontinuance . Artific ial respiration can only beproductive o f permanent results when ,

at the same time,there o ccurs ,

as well through the vessels o f the lungs as throughout the entire ram ification o f the aorta, a life-suppo rting c irculation o f blo od. The artifi

cially excited action o f the respirato ry o rgans may, however, bec omeultimately the cause o f the reinstatement o f the exc itability Of the ner

vous centres, and thus b e the means o f rec alling the normal ac tivity o fthe respiratory muscles . Resuscitation,

in the cases embraced by thefourth pro po sition, is to be effected by the remo val Of the impediment

,

by a sucking effort Of the operato r’s mouth applied directly to them outh o f the infant, or through an elastic catheter pas sed into thelarynx , o r by a syringe and elastic tube . Amer . Journ . o fMed.

On the co lour of the eyes of the newly born—Dr . Wiltshire Lancet,

’

Feb . 1 I , 187 1) believes that the eyes in newly born chilren are a lwaysOf a blue c o lour. It is a slaty, mercurial Oin tment, o r leadenblue, generally different from the blue co lour which Obtains inafter life . A change is usually o bservable in the second m onth . If

the eyes are to become dark,” a brownish hue o verspreads the leaden

428 REPORT ON MIDWIFE RY , E TC .

pro duced in the development o f the allanto is is large between the sixthand seventh week , s o we must lo ok anterio r to this time fo r the cause .

He thought it probably due to an o b struction to the free circulation o f

blo od in the veins o f the left side o f the vascular zone .

Mr. Macgillivray relates a case o f c ongenital hypertrophy of the lefthand and arm, for which he ligatured the brach ial' artery with a suc

cessful issue . Austral . Med. Jan .

Dr. Bailey, in an article on trismus nas centz’

wm,in the Amer.

Journ . 187 1 , quo tes the opinions o f several autho rities on thesubject, and says that in his experience, since 1853 , he has n ot observeda single case o f lo ckjaw when due regard was paid to the managementand dressing o f the umbilicus . Tumefaction and redness

,without sup

uration should always exc ite apprehension . Unsuitable dressing,bo th befo re and after the separation o f the c ord, are c omm on exc itingcauses . In the early stage o f the disease so o thing applications to theumbil icus are o f great service . Dr . Bailey do es no t think that negroinfants are m ore liable to it than white children .

Dr. Widerhofer, o f Vienna,speaks highly o f the value o f chl oral hy

drate in the treatment o f tetanus neonato rum . He has had six cas es

(out o f ten o r twelve) ofreco very under treatment by chlo ral . Lancet,

’

March 18, 187 i .)Ric/teta—Dr. Blache

,o f Paris , writes Practitioner,’ Sept. 1872 ) on

rachitis and minera l inanition . He quo tes the c onc lusions o f Dusart :

That in all living beings, whether vegetable o r animal,the pre

sence o f pho sphate o f lime is necessary fo r the transfo rmation intocells of the azo tized matters supplied by fo od, and that to preservetheir vitality the tissues must b e c onstantly traversed by a kind o f

current o f pho sphate o f lime ; (2 ) that the vital . a ctivity peculiar toeach spec ies is a lways in proportion to the quantity o f pho sphate o f

lime contained in it ; and (3) that when the fo o d is defic ient in pho sphate of lime the tissues draw from the o sseo us skeleton that which isnecessary fo r nutrition . He then inquires by virtue o f what action doalbum in ized substances assume, in presence of calcareo us pho sphate

,

the fo rm o f cells,and o f tissues o f every nature without its being demo n

strated that the salt o f lime fo rm s any c onstituent part o f them .

Knowing the property po ssessed by salts o f lime o f prec ipitating album en in an in so luble s tate, may it no t be adm itted that there takes placein the o rganism an analogous phenomen on, but with this m odification,that in the living medium this prec ipitate assumes the figured fo rm and

becomes o rgan ised in tissues If children to o young or persons dehilitated from various causes are subjected to a c o urse o f alimentation ex

elusively compo sed o f the flesh o f young animals,the liquid albumen

will be easily abso rbed, whilst the so lid parts c ontaining the salts o flime will resist the action o f the debilitated stomach, and will be ejec ted.

It is no t o rganizable elements wh ich are wanting, but an o rganizingagent, and m ineral inan ition ensues indirectly as surely as by administering aliments defic ient in salts o f lime

,such

,for instance

,as wheat

alone. Blache believes that the go od effected by c o d-liver o il in ricketsis due entirely to the exc iting action produced thro ugh the who le ex

tent o f the digestive tube by the vo latile o ily acids to which it owes its

THE INFANT. 429

well-known o dour. The regular c ontractions o f the digestive tube, andespec ially the glandular secretions , reappear, and this double influenceprom o tes the digestion o f the so lid parts o f fo o d, which had till thenresisted . The s ame result is o btained by presenting direc tly to theab sorption o f the stomach pho sphate o f lime, on the c ondition that itbe so luble and require n o labour for its digestion . The pho sphatetaken into the weakened stomach o f persons afflicted with rachitis willundergo no m o dification . He rec ommends Dusart

’

s lacto pho sphate o f

lime, which is prepared by im itating the action o f the gastric juice on

pho sphates, and which contains the salt c ompletely digested, and c on

sequently capable o f being abso rbed without requiring any previouslabour o f the stomach .

Dr . Widerho fer, in som e rem arks on the differential diagno sis ofs light cases of rickets and of chronic hydro cep ha lus , says the p o ints tobe attended to are chiefly these . In rickets the fo rm o f the head ismore o r less angular, b ut there is no spec ia l dispro p o rtion between thehead and the face . The anterior fo ntanelle may be large, but thesagittal suture is general ly c lo sed at eight o r nine m onths . T he o rbitsare no rmal and there is no prominence o f the co rnea . Further

,some

alterations in o ther parts o f the sketeton,e.g . heading o f the ribs

, o r

some enlargement o f the ep iphyses o f the radius and ulna , will probablybe present . In chron ic hydro cephalus the skull is inclined to a globularshape ; the sagittal suture is open ,

as well as the fontanelle ; the headis large, o ut o f pro po rtion to the face, and there is divergence outwardof the tempo ral bones at their upper part, in stead o f their usual verticalpo sition . From the pressure o f the intra -cranial effusion the upper

wall o f the orbit tends to bec om e m ore and m o re upright, s o as to pushfo rwards the eyes and expo se the c ornea . Further

,in rickets, the

tendency is to p artia l convulsions, espec ially spasm o f the glo ttis ; inhydro cephalus to genera l c onvulsions . Lastly

,the former is m o st

frequently ac companied by diarrhoea ; the latter by c onstipation .

Lancet,’ March 1 8,

Dr. Ritchie writes o n the diagno sis o f rickets Med. Times andJan . and po ints out

,as the result o f numerous observa

tions,that there is a varying fall in the even ing temperature in rickets

,

whereas in tuberculo sis there is not only no evening fall , but there is apo sitive evening rise .

Dr. Sonsino,in a paper on the p hysio logica l @sp ep s ia for s tarchy

foool in infancy , c onfirm s the o pin ions o f Bidder and Schm idt, Guillot,and S chiff ; and c oncludes that in the generality o f mamm alia

,saliva

acquires its digestive p ower o ver starchy matter only at a degree o f

development which , in the larger number o f the same animals , is no treached at the time ofbirth . He then deta ils some experiments made withan infusion o f the pancrea s o f young animals

,and states that pancreatic

juice in dogs , cats , and rabbits in the first week o f life is devo id o f anydigestive action on starch and he infers that the same inability o f thepancreas to digest starch exists in the early life o f man . E xperimentsmade with the enteric juice were no t s o c onc lusive . He thinks thatan infusion o f fresh pancreas m ight be useful to aid the digestion o f

starch in infancy ; but that go od reasons exist for not feeding infants

430 REPORT ON MIDWIFERY, E TC.

with starchy matters, however they may be rendered digestible . Thenutriment furnished by starch do es no t afford materials fo r the re

integration o f the princ ipal tissues , but it c oncurs almo st exc lusively asfuel to the pro cess o f hemato s is , whereas the growing infantil e o rganismneeds a greater quantity o f tho se nutriments which directly affo rdmaterials to the develo pment o f the tissues . Practitioner

,

’Sept.

18 2 .

Dr.

)Dobell believes that many c ases o f infantile wasting o c cur

because the fo od, deficient in fat, no t only fails to nourish the child,but fails to develo p the function o f the pancreas for the digestion of

fat at a later perio d o f life . T he craving o f the child, due to the

deficiency o f assimilated fat, is met by starchy fo o d which it has no t

the power to digest, and which , if digested, canno t supply the place o f

fat . Of all the satisfac to ry remedial effects o f pancreatic emulsionnone equal tho se pro duced by it in these cases o f wasting in children .

Prac tioner,’

O ct .

Co ld Fo od f or Infants—Surgeo n King writes in the ‘PhiladelphiaMedical Times ’ on this subject Our best authorities direc t thatthe c ow ’s m ilk should be given to the child at the same temperatureas that o f the m o ther’ s m ilk

,from 90

°to 95

° Fahrenheit, and whengreat accuracy is required a thermometer employed. On reflection

,it

is o bvious that these instructions c an never be carried out s o that thelittle one will take all its fo o d at the same temperature, fo r during a

meal the bo ttle becomes c o ld, and there may frequently be considerabledifference o f temperature between the first and the last m ilk imbibedby the infant . It is unnecessary to state that very little will upsetthe feeble p owers of the digestive o rgans in the early days o f infantilelife

,and this difference in the temperature o f the fo od, I am dispo sed

to believe, is one o f the causes o f gastric and intestinal disorder whichwe so o ften have to deal with among infants bro ught up by hand.

Instead o f giving warm m ilk,I have ado pted the plan o f giving co ld

milk entirely—ordering the babe’ s bo ttle to be kept standing in icedwater in the summer and in a co ld place in winter. This method Ihave found, from practical experience, to answer remarkably well . If

there is any tendency to diarrhoea I recommend the m ilk to be heatedto 2 1 2

° Fahr. , and afterwards allowed to get quite co ld before beingused. In private prac tice I am o f o pinio n that bo ttle-fed infantsgenerally have their fo od given them to o warm . They so on like itbetter than warm fo od, and during the teething period co ld milk seemsespecially agreeable to the inflamed gums o f the little sufl

'

erers .

”

Brit . Med. Aug.

Vaccination—Mr. Hutchinson c ontributes an important report ontwo series o f cases in which syp hilis was communicated in the p ra ctice

of vaccina tion . The first series c onsisted o f twelve persons , mo stlyyoung adults , who were vacc inated from a healthy lo oking child. The

progres s o f the vac c ination was satisfactory in all ; but induratedchancres appeared on the arms o f ten o f the vaccinated in the eighthweek . The primary so res rapidly disappeared after mercurial treatment, but c onstitutional symptom s a peared in four o f the patientsfive months after the vaccination, an the vaccinif'er showed condy

482 REPORT ON M1DW1EERY , E Tc.

vaccine so oner, but the pustules had appeared the same mo rning, andthe patient died on the 3 1st . Ano ther child suckled by the same nursewas successfully vac c inated on the 2 7th ; but was seized on the n inthday with a very m ild fo rm o f vario lo id and did well . The nurse presented on the 1 0th o f February five pustules around the n ipple o f the

right breast . These c ommenced o n the 4th o f February . There hadbeen

,and there was no o ther part attacked, no t even the o pp o site

breast, which , as it was the seat o f an absces s, had no t been frequentlyused. Guilland regards this case as an instan ce o f true ino culationfrom the nursling to the nurse . Being pro tec ted by early vac c ination ,

she was susceptible only o f a lo cal cflect . Lyon April,A foetus expelled in the s ixth m onth o f pregnancy, while the m o ther

was suffering from smallpox ,had distinct ustules all o ver its surface .

(Simpson,

‘E din . Med. J May, 1872 . See a case o f incubationo f smallpo x in utero . (Townsend, Med. Times and June,

See also the case o f a foetus bo rn with a pustular eruption ,

the mo ther at the time suffering from smallpox . (‘Lyon O ct.

1 8

li’o llak writes on haemorrhage from the kidneys in infants (‘Wien .

Med. Presse,’ xviii, It is liable to fo llow severe attacks o fdiarrhoea in infants under two m onths Old. In addition to the appearanoes o f the urine there is p ain pro duced by pressure in the lumbarregions, and there is also great restlessness . Po llak thinks , from po stm o rtem exam ination , that the parenchyma o f the kidney is not the seato f disease. The yo ung patient ’s strength should be kept up by go odm ilk and by tonics . Reco very is rare .

T he Jawndice of N ewly-born Children—Dr. Kehrer believes that first

born children are rather mo re frequently attacked than o thers . E arlyurging o f the meco nium do es no t hinder the development o f jaundice .

%Ve must , then ,abandon the idea that the jaundice is caused by resorp

tion o f the meconium , which is rich in bile in newly-bo rn children . In

jaundice in newly-bo rn children we find the liver throughout, o r in

parts , yellow c o loured, from the bile co ntained in the liver-cells .Frerichs thought ic terus neonatorum due to dim inished tonic ity o f thecapillaries o f the parenchyma o f the liver, which takes place when the

flow from the umbilical vein is sto pped, and permits o f in crease o f bilein the blo o d. Hardenhain adm its that after c ompression o f the ao rtathe pressure o f the secretion in the duc tus cho ledo chus falls o ff.Virchow thinks that infantile jaundice results from catarrh and sto ppage o f the bile-duct. The disease c ommenced usually on the secondo r third day, and seldom on the first o r fourth day o f life. Theprogno sis is generally go od. (See

‘Amer. Journ . o f Obstetrics, ’ Nov.

Guénio t relates Gaz . des April,1872 ) a case o f congenital

invagination o f the rectum . Dr. Dawson related to the New Y o rkObstetrical So c iety the case o f a child six weeks o ld

,who was the sub

ject o f an invagination o f the c o lon , caecum , and a portion o f the duodenum into the rectum

,and which were bound together by exudation

where the peritoneal surfaces were o ppo sed. T he diagno sis had no tbeen made during life . Amer . Jo urn. o f Nov.

RE P O R T

MED I CAL JUR I S PRUDENCE .

THOMAS STEVENSON ,M .D . LOND .

,

URER ON CHEM ISTRY AT GUY’S HOSP ITAL ; MEDICAL OFFICER OF HEALTH FOR

ST . PANCRAS, M IDDLE SEX, AND OFFICIAL ANALY ST ; LAT E EXAMINER IN

FORENSIC MEDICINE IN THE UNIV ERSIT Y OF LONDON .

POISONS .

Genera l .—Pro f. Cro ltz,

1o fHalle

,has experimented on the abso rption

and removal o f p o isons after suspension o f the c irculation , and has

arrived at the fo llowing results —1 . In frogs , the hearts of which hadbeen previous ly ligatured, strychn ine n itrate injected into the stom achinduced tetanic spasm s within fifteen m inutes , and the same resultsensued when the p o ison was injected beneath the skin . 2 . The po isonreaches the spinal c o rd Spite o f the ligature applied to the heart, forfrogs were fed with the Sp inal c ord o f ano ther frog which had beenpo isoned by the injection o f the po ison o ver the mus c les o f the calfsubsequent to the ligature Of the animal’s heart, and yet tetanus supervened after the lap se o f eight ho urs . 3 . The passage o f the alkalo idfrom the region Of the calf to the sp ina l c o rd is independent Of theactivity o f the striped muscular fibres o f the p o isoned limb . When theheart was ligatured, the ro o ts o f the ischiadic nerve o f one side dividedin the pelvis, and then the stychnine salt injected into the calf on the

same side,tetanus supervened. 4 . The blo od is the vehic le by which

the toxic sub stance is dis sem inated, fo r when frogs were destroyed bystrychnine subsequent to ligature Of the heart the blo od o f thesepo isoned an imals was capable o f induc ing tetanic spasm s in o ther frogs .5 . If a frog

’ s heart be ligatured, and the animal be now po isoned bythe introduction o f the strychn ine salt into the leg, the po ison passesinto the oppo site limb , fo r if ano ther frog be fed with the musc lesfrom the first po isoned frog the sec ond frog experiences tetanic spasms .6 . The experiment last detailed fails if a dead frog b e employed fo r thestrychnine injec tion in the first instance .

—The author is o f opinionthat the general princ iples enunc iated abo ve are applicable to p o ison sgenerally, and states that even after c omplete interruption o f the cir

culation a po ison may pass from one part to ano ther o f the living bo dyby a pro cess different from the o sm o sis which takes place in the dead

it Arch . f. Gesam . 1871, 147°

434 REPORT ON MEDICAL JURISPRUDENCE .

tissues,

and he prom ises further experiments on the fo rce wrenders this translation po ssible .

E limination of pois ons .—Dr. Anstie 1 combats vigorously the

valent views with respec t to the suppo sed elim inationanimal, vegetable, and m ineral . He appears toi s no tendency in the unaided animal o rganisand that remedies administered with the Object o f assistingare, as a rule

, powerless .Antagonism of P o is ons .

The literature o f this topic is unusually interestingAntagonism

research on thDr. Fraser.

2

ments , so that, on the weightan eas matter to be certaintion t at coul d kill them .

recover fo llowed the admini

in c om ination with a

o f, the min imum fatal,wards

,and, when the

3? ‘The Practitioner, ’ vi ii, pp . 161, 289, 356.

T Trans . Roy. So c . 1872 , xxvi, pp . 5 29—7 13 .


o f the two substances successful antagonism o ccurs . The fo llowingare the resul ts obtained

I . E xp eriments with the minimum letha l dose of hysostigmine.

While O '

o o 5 grain Of sulphate o f atropine is a do se ideath , o ‘

o o g grain is one sufliciently large to dosulphate o f atro pine ranging within the wideo

’

o o g grain to grains is able to prevent theo f physo stigmine ; but if the do se o f sulphate o f atropin5

°

3 grains the region o f suc cessful antagonism is left and death o c curs .E xp eriments with one and a ha lf times the minimum

.

letha l do se of0 0 15 gra1

phate o f atro pine.

and below this range death o c curs .E ap erinnents with two and a half times the mininwm letha

p hys os tigmine—The range here is from O

'

o 2 5 to grains o f

o f atro pine . Beyond and below this death o c curs .With

case theo f sulphWith

-Here the range is a very limited o ne, extending from O'

I to O 2

o f sulphate o f atro pine .

With fo ur times the minimum letha l do se of hysostigmine.

case no successful antagonism can be exerted7

by atrop ine,invariably ensues .The results o f these experiments are all represented diagramat

In ano ther series o f experiments the interesting fact is bro uthat death may b e likewise produced by the c ombined non-lethalthe two substances . When sulphate o f atrop ine i s administem inutes befo re half the m inimum lethal do seo c curs if the do se o f the fo rmer substance b e 9result is a very remarkable one when it isdec ided counteraction is exerted by much small er do ses o f

against the po isonous ac tion o f do ses of physo stigmine greatlyo f the m inimum lethal

,and that the m inimum lethal do se o f

o f atrop ine is about 2 1 grains .II . Determination of the limits of antagonism when atrop in

adminis teredfive minutes after p hysostigmine.

E xp eriments with the minimum letha l dose of sulp hate

mine (O'

I 2 gr. p er 3 lbs . weight) .—The range of antagonism

and grains o f sulphate of atropine.

POISONS . 437

With one and a ha lf time the minimum letha l dose.—The range lies

between and grains o f atrop ine .

PVith twice the minimum letha l dose the range is from O°

I to I'

d

atropine.

three times the minimum letha l dose the range is still m ore

rec o very taking place only in one place in which grainwas adm inistered.

three times m ore than the minimum lethal do se o f physostigm ine canno t be successfully antagonised by atropine .

Ano ther set o f experiments shows that the smallest quantity o fatrop ine that, in c onjunction with half the m inimum lethal do se o f

phys o stigmine administered five m inutes befo rehand, is suffic ient tocause death, is about ten grains per three pounds ’ weight o f rabbit .III . Determination of the influence of the interva l of time between the

a ch ninis tration of the two subs tances up on the dose of atropinerequired to countera ct a given dose qf

‘

p hysos tigmine.

The p lan o f this third series o f experiments was that the do se o f

physo stigmine was c onstant (one and a half time the m inimum lethaldo se

, viz . sulphate o f physo stigm ine per 3 lbs . weight o f animal) ,While the do se of atrop ine and the interval o f time between the ad

m inistration Of the two substances varied. The experiments are—(a)tho se in which the two substances were simultaneously adm inistered ;(6) tho se in which atropine was adm inistered after physo stigm ine (0)tho se in which atropine was adm in istered befo re physo stigm ine .

(a) In these the range o f successful antagonism lies betweenand grains of atropine .

(b) T he results o f administering atropine five minutes after physo stigmine have already been given . Ten minutes afterwards : the range

in this case is from 0°

3 to 2°

5 grains o f atropine . Fourteen minutes

afterwards only one experiment was made, in which 0 °

3 grain sulphateof atro pine was suc cessful . Fifteen minutes afterwards death is prevented by do ses of atrop ine ranging from 0

°

3 to 1 grain . Beyond thisinterval atrop ine do es no t antagonise physo stigmine.

(0) Five minutes befb re : the range of suc cessful antagonism i s fromto grains o f atrop ine.

Ano ther set o f experiments with varying do ses o f atropine, administered at different intervals before the m inimum lethal do se o f physo sztigmine, shows that grain exerts successful antagonism with an

interval o f twenty m inutes or less, but n ot if the interval be pro longedbeyond this .Do ses Of half a grain o f atrop ine antagonise one and a half time the

minimum lethal do se Of physo stigm ine, if adm inistered thirty m inutesbefore this

, but not if the interval be longer . Do ses of one grain and

a half antagon ise physo stigm ine within an interval of sixty-five m inutes .Three grains o f atrop ine adm inistered an hour and thirty-five m inutesbefore the same do se o f physo stigm ine successfully antagonise it, butnot if the interval is pro longed to one hundredm inutes orm ore . Threegrains , however, is near the maximum limit of the range in the case o f

simultaneous administration, and, accordingly, not far from the limit in

438 RE PORT ON MEDICAL JURISPRUDENCE .

the case where atropine is admin istered five m inutes befo re physo stigm ine .

Ano ther set of experiments shows this remarkable result,that if four

and a half grains o f atropine are given ten m inutes before the physo stigmine, death o c curs, but reco very takes place if the atro pine is adm inistered fifteen o r twentym inutes before. When five grains o f sulphateo f atropine are administered befo re the same do se Of physo stigminedeath o c curs if the interval of time b e one o f fifteen o r twenty m inutes

,

but reco very generally o ccurs if the interval b e one inc luded within thewide lim its extending from twenty-five to one hundred and seventy-fivem inutes ; while death, again, o ccurs if the interval b e one so great asthree hours .A very interesting chain o f events is therefo re presented

,for it is

seen that certain actions, pro duced with suffic ient intensity to causedeath when the two substances are simultaneously administered, lo sethe power o f do ing s o when the atropine is adm inistered at an intervalOf twenty-five m inutes before thesoured c ounteraction o f the lethalwhich makes the lo ss perceptible,to three hours .The who le o f this remarkable

trated by diagrams .sive manner to exertto the o ther, and tha

existence o f such an antagonism enc

directly counteracting disease is fara strong incentive to effo rts designdisease and the actions o f remedieshow how the remedial action may bence to the diseased condition .

”

Antagonism of various p oisons—Pro f. o f Pennsylvania, has

investigated the fo llowing an po sed antagonistic po isons —Mo rphineand atropine, m o rphine and hydro cyanic ac id

,m o rphine and strych

nine,m o rphine and aconitine, m o rphine and arsenic

,strychnine and

tobacco,strychn ine and ac onitine, strychn ine and tincture o f chloride

o f iron,strychnine and tincture o f io dine, strychnine and Calabar bean,

d atropine and Calabar bean .

The antagonism between hydro cyanic acidto be very slight, if, indeed, it exists at all .

o f atro pine and m orphine coul d no t b e satisfa

in no sense,he

and to bac c o beas relates to thrities that tobaof strychnine.

if ‘Amer. Journ. Med. lxi, pp . 133, 373 .


quence o f the action of the fo rmer,sometimes, however, of the latter

agent . 6 . Hence strychn ine 1s no t an antido te fo r chlo ral .P hysostigmine and s trychnine.

—Ashmead* describes a case o f suc

cessful treatment o f strychn ine p o isoning by m eans of extract o f

physo stigm ine . A drachm o f the pharmaco poeial so lution o f strychninehad been swallowed. Reco very to o k p lace after the adm inistration o f

a little m ore than two grains o f the extract Of physo stigm ine.

Dr. J . St. Clair Gray? propo ses nitrite o f amyl as an antido te fo rstrychnine .

Aconite and digita lis .—Dobie1repo rts a very interesting case in which

reco very to ok place from a p o is onous do se o f tinc ture o f aconite treatedby the subcutaneous injec tion o f tincture

z

o f digitalis . The patient , whenseen , was pulseless and apparently at the po int of death . Twentym inim s o f the tincture o f digitalis were first injected subcutaneously .

G alvanism was also applied to the ca rdiac region . At the end o f twentym inutes the patient was able to swallow

,when he received along with

brandy and ammonia a teaspo onful o f the tincture . Impro vementfo llowed, and the m ixture was repeated twice within an hour. After thisthe patient was out o f danger. He subsequently go t quite well, andc onfessed he had swallowed an ounc e of Flem ing’ s tincture o f aconite.

The case is lo oked u on by the autho r as pro ving that digitalis i s a

cardiac stimulant , an no t a cardiac depressant, as some suppo se .

P ho sp horus p o isoning .—Dr. Lichten stein§ re orts a case in favour o f

the views o f Perso nne, Andans , KOhler, and o t ers,that o il of turpen

tine 1s an antido te fo r p o is oning by pho spho rus . Dr. S chul tzenn | states ,that in an experience o f thirty o r fo rty cases nearly o ne h terminated favo rably, no twithstanding that no Oil o f turpentine was given .

Dr. A . Welterfll has an elabo rate m onograph on pho spho rus po isoninggenerally, but the chief po int in his paper is that o f treatment . He

appro ves of the treatment by o il o f tu entine,but states that the

rectified Oil 1s unreliable . He recommen s the French o il o f turpentine . We m ay remark that five kinds Of the o il are met with in c om

merce—French , E nglish , German ,Venetian ,

and Templin o il,which

differ c onsiderably in c ompo s ition and Optical ro tato ry p ower. T he

fo llowing 1s Vetter’8 c ourse of treatment . In acute cases he first givessulphate o f c opper in em etic do ses every ten o r fifteen m inutes tillvom iting is pro duced.

several do ses have to beneutralizes the pho sphorus . After tho rough vomitiGal licum is given in 40 m inim do ses every fifteenbeing the medium employed fo r the exhibition of the remedy .

magnesia is given .

G . H . Ro essingh** makes some observations on the treatment

E din. Med. 1872 , p . 2 35 .

f Glasgow Med . Journ Feb ., 187 1, p . 188.

i‘Brit. Med . Dec . , 1872 , p . 682 .

Berl . Klin . 1870, No . 33 .

H‘Centralbl . f. (1. Med . Oc t. 8, 1870 .

1T‘Virch ow ’

s li ii, p . 168, 187 1 .

W “ Schm idt’s J c lvi, p. 19.

POISONS . 441

acute pho sphorus p o isoning with c opper and Oil o f turpentine. Hisexperiments were m ade on rabbits . The c onc lusions he has arrived at

are as fo llows (1) The statem ents o f Bamberger, that o il Of turpentineas an antido te to pho sphorus is inert, are erroneous ; (2 ) all the ani

mals which were treated with turpentine, after having been po is onedwith pho spho rus , lived longer than tho se which received c o pper ;(3) the do se o f ph o sphorus which c ould b e b orne when turpentine wasgiven was much greater than that where c opper was employed as an

antido te ; (4) the temperature never rises s o high when turpentine isadministered as when c opper is used ; 5) owing to the great rise intemperature anim als po isoned with pho spho rus lo se weight m o re rap idlywhen treated with c opper than when treated with turpentine. In

addition to these facts, the an imals which were treated with Oopper weremuch stronger physically than tho se treated with turpentine . As anexample o f the influen ce of turpentine, he gives the fo llowing experi

m ent . T o one rabbit 2 5 m inim s o f pho spho retted o il along with80 m in im s of Olive Oil were given ,

to ano ther the same do se of pho spho rus along with 80 m inim s o f Fren ch Oil of turpentine . The firstdied, the latter remained quite well . He regards turpentine as the

best antido te to pho spho rus .Tis sue changes in p ho sp horus p oisoning

—V o itif and Bauergnvestigate

pho spho rus po isoning in relation to the fatty degeneration o f the tissuesand o rgans which it c auses . By giving pho spho rus to dogs deprived o f

fo od for several days they found that the o rdinary symptom s o f

pho sphorus p o is oning and fatty degeneration o f all the o rgans wereproduced. The fat c ould no t have c ome from the fo od

,as the animals

were in a state o f starvation,no r from the o ther parts o f the bo dy

, as

there the fat had all disappeared fo r the sam e reason . It must thereforehave been pro duced by the decomp o s ition o f the album inous tissues .They show by experim ent with Vo it’ s respiration apparatus that inpho spho rus p o ison ing the fatty degeneratio n is due b o th to diminishedo xidation o f fat and to its increa sed production from the transformationo f a lbum en . They find with Schnltzen and Riess that the urea i sincreased, but they found no abnormal pro ducts in the urine, except infatal cases a little sarc o lactic ac id. They did no t find leuc in o r tyro sinin the urine

,but found these abundantly in the liver

,heart

,and blo o d o f

dogs p o isoned with pho spho rus . The n itrogenous pro ducts Of thedec omp o sition Of albumen are therefore c onverted into urea in all casesin the dog, and in slighter cases o f pho spho rus p o isoning in m an . In

severe cases in man the decomp o sition is imperfect, and the higherpro ducts of decomp o sition are excreted. They think that the greaterrapidity o f degeneration in acute yellow atrophy of the liver is the chiefdifference between this disease and pho spho rus p o isoning .

Corrosive P oisoning.

Sulp huric a cid—Cases of fata l po isoning by this substance are

related by Malmsten and Schauenburgrt'

3“ Journ . Chem ical N. S ., ix [xxiv], 46 ;cN. Rep . Pharm. xx, 0.

‘

l‘ Schm idt’ s clv, p . 7,

P 9 P 34


Nitric acid—Stevenson"? relates a case o f suicidal po isoning withabout three ounces o f nitric ac id. Death resulted in seventeenhours . In this case there was perfo ration o f the stomach and ulceration o f the c o lon . The perfo ration apparently o c curred after death orjust before it . T he ulceration o f the c o lon may have pre-existed .

O ther cases are reported by Malmstend'

and by Dougall .IHydro chloric a cid—Fatal c ases o f p o isoning by hydro chlo ric acid

are detailed by Drs . G . Johns on,§ Paul, ” and NagerfilAmmonia—Stevenson“ relates a case of po isoning by a teaspo onful

o f the strong liquor amm onise,sp . gr. 8 8. Death supervened quite

suddenly, without asphyxia .

Castanflr describes the symptoms resulting from the inhalation of

ammonia vapours .Caustic p otash

—Nagerii describes a case o f po isoning by causticpo tash which pro ved fatal in twenty-two hours under symptoms of

lobular pneum onia .

Nitrate of silven—T . Scattergo od§ § gives details of a case o f po ison ingby nitrate o f silver. A student , while applying a stick o f lunar caus ticto the thro at o f a fifteen-months child, ac c identa lly let the piece drop outo f his fingers , and it was swallowed by the child. The piece was threequarters o f an inch in length . Vom iting o f the contents o f the stomachimmediately fo llowed. Large quantities o f common salt were given ,

vom iting o c curring repeatedly . Diarrhoea set in and c onvulsions, under

which the child died, six hours after the c ommencement o f the symptoms . The chief p o st-mortem appearances were c orro sion o f the greatcurvature o f the stomach and superfic ial corro sion o f the duo denum andcommencement o f the jejunum . No nitrate o f silver was found in thecontents o f the stomach , as it had all been decompo sed b the antido te .

Chronic lead p oisoning. has made chronic lead po isoningthe subjec t o f an expenmental research , with special reference to thetheo ries o f Henle and o thers , that lead exerts a specific ac tion on the

pale and striated muscular fibres . Analysis of the viscera o f four dogswhich died under symptom s o f eclampsia saturn ina showed that inchronic lead po isoning the bones contain the largest quantity o f

lead,next the liver and the kidneys . The central nervous organs

c ontained less , but a greater quantity than the musc les, intestines, andblo od

,&c . He therefo re denies a spec ific affinity o f the musc les fo r

lead. That the symptoms o f lead po isoning are due to spasm o f the

blo od-vessels , as stated by Henle and Hitzig,he considers disproved

by the state o f the pulse during an attack . That it acts directly onGuy

’s Ho sp . 3rd ser. , xvn, p . 2 2 3 .

1° Schm idt’s J c lv, p . 7 .

I Glasgow Med. J 1872 , May.

‘Brit. Med. 1872 , p . 2 2 1 .

Bull . Gén . de Oct. 20, 1872 , p . 364 .

11 Arch . d . 1872 , p . 2 13 .

Guy’s Ho sp . 3rd ser.

,xvu, p . 2 2 5 .

H Mo ntpellier Nov. 187 1, p . 577 .

II‘Arch . (1. 1872 , p . 2 13 .

Brit . Med. 187 1, p . 5 2 7.

H“ ‘Virchow and Hirsch ’ s Jahresber.’ for 1871, i, p. 316.


the po ssibil ity o f separating it from blo od by m eans o f the vacuum .

Zuntz,however, has suc ceeded, by Pfliiger

’

s gas pump , in extrac tingthe carbonic oxide . The chief p o int in the research is that the gas isonly given Off fitful ly and by repeated exhaustions o f the receiver. His

experiments acc ount fo r the statements that c arbon ic o xide canno t bes o rem o ved from blo od, as the pro cess was suppo sed to b e finished afterthe first exhaustion . These results must mo dify c ommonly receivedOp inions regarding carbonic oxide po i son ing . There is no need to supp o se that the carbonic o xide canno t b e expelled as such , but requiresoxidation into carbonic ac id. So long as the heart beats there is reas onto ho pe that, by means o f energetic artific ial respiration, the blo o d mayb e again restored to its normal c ondition .

Podo linski” < c onfirm s the statements ofDonders andZuntz, and shows,in addition

,that no t only may carbon ic o xide b e expelled from blo od by

indifferent gases, but that n itric oxide comes under the same category .

N itric o xide may be ex

pelled from its haem oglobin compound by means

o f indifferent gases, suc as hydrogen . The oxygen ,carbonic -oxide

,and

nitric-oxide haemoglo bin c ompounds are thus in agreement with eacho ther. Oxygen is mo st easily expelled, next c arbonic o xide, and la stlynitric oxide . E ach gas can be m ore easily expelled by the one immediately fo llowing than by an indifferent gas , and each , again, can likewise be m ore easily expelled by the one immediately preceding than byany o ther indifferent gas .

R . and R . S . T urnerT contribute a very interesting account o f thesymptom s and po st-mo rtem appearances in severa l ca ses o f carbonico xide po isoning, resulting from the c ombustion o f c oal and peat inc lo sed chambers .Oxysulphide of carbon—Dr . S . Radziejewski,j: working in Liebreich ’s

laborato ry, has investigated the ph sio logical ac tion o f this gas , disc o vered in 1867 by Than . Oxysulpfiide o f carbon appears to be widelydistributed in nature

,

”

giving to many sul phuretted waters their peculiar sweet taste and aromatic o dour. It is also a probable c onstituent o fthe gases evo lved in vo lcanic districts

,and is , perhaps , given o ff during

the putrefaction o f o rganic substances c ontain ing sulphur. Its c omposition is represented by the formula COS ; it is, in fact, intermediatebetween carbonic ac id and bisulphide o f carbon . It is abso rbed bywater, and slowly decomp o sed by this into carboni c ac id and bisulphideo f carbon . The gas pro duces in animal s toxic effects

,which resemble

tho se o bserved by Ro senthal and Kaufmann in intoxication by sulphuretted hydrogen . Radziejewski suppo ses that o xysulphide o f carbonabso rbed into the blo o d sp lits up, in c onjunction with water, into car

b onic ac id and sulphuretted hydrogen, a decompo sition which takesplace, as we have already stated, Outside o f the body . To this viewthere are

,however

,some objections . The o xysulphide is less so luble

in dilute alkaline so lutions (and hence in the blo od) than in water, andeven in this latter the dec ompo sition o f the gas is very tardy, whilstthe oxysulphide is m o re rap id in its toxic actions than sulphuretted hy

Pflluger’s Arch iv f. Phys io logie, ’ vi, p . 5 53 .

1‘E din . Med . J March , 187 1, p . 106.

I‘Virchow’

s liii, p . 370 .

POISONS . 445

drogen . No twithstanding that o xysulphide of carbon is a chemicalcurio sity, it i s so widely distributed in nature that its po isonous actionis a p o int o f much interest .N itrous ovide.

—Purcell* reports a case o f death from the inhalationof nitrous o xide . A woman ,

2 0 years o f age, apparently healthy, diedsuddenly after four teeth had been extracted, while under the influenceo f nitrous oxide . The cause of death was supp o sed to be asphyxia .

Little c ongestion o f the lungs was found, however, and sho ck seemedto be the real cause o f the fatal result .Carbo lic a cid—T he toxico logy o f this substance, now so extensively

used in medic ine, has Of late received much attentiond'

and fatal caseshave frequently resulted from its adm inistration either by acc ident orfor the purpo se of self-destruction . Its use as a remedial agent hasalso been put to m ore rigid and extended tests .Salkowski found carbo lic ac id to be useless as a remedy in smallpox .

In gangrene Of the lungs it was m ore suc cessful when given in the formo f pills . If given in the liquid fo rm ,

the so lution must be highly dilute,for a one per cent . so lution causes thickening o f the stomach . The

remedy was found to b e useful in gastric affections . The use o f the

pure diluted ac id never causes pain ,nausea

,o r vom iting. This Oh

server has also carefully inquired into the physio logical effects Of car

b o lic ac id,and his results are of great interest . When injected into

the blo o d carbo lic acid pro duces b o th lo cal and general paralysis , andthe musc les penetrated by the substan ce shrink and their fibreslo se their electric exc itability. When injected the heart’ s beats dec line infrequen cy to nearly one half. Convuls ive m o vements are also set up ,simulating tho se pro duced by strychnine, and these may be exc ited inthe upper extrem ities after the pro longed therapeutical employment Ofc arbo lic ac id as a remedy . The fo llowing is the cause o f the symptom sobserved in rabbits —A few m inutes after the adm inistration o f the

ac id fibrillary qu iverings o f the muscles may be no ted, then m ore dis

tinctively c onvulsive m ovements . T he an imal c ontinues to run about aotively, but the tremors increase in severity . Resp iration becomes s lowand the animal bec omes restles s . The limbs gradually lo se their power,and eventually the rabbit falls on its side . In endeavouring to rise,c lon ic spasm s

,salivation

,and dilatation o f the pupil are exc ited. Sen

sibility is diminished, and with lethal do ses o f the pheno l graduallydiminishing tonic and c lonic spasms are exc ited. The urine is seldomtinged with blo od, nor is it album inous . The detailed co urse o f symptoms appears to b e dependent o n an action o f the p o ison upon the centra lnervous system ,

and must no t be c onfounded with the lo cal paralysis atfirst produced by injection o f pheno l .Carbo lic ac id is quickly absorbed into the c irculation, and rapidly

excreted, so that there is no fear o f its exc iting a cumulative effect . Apart o f it is oxidized in the c irculation into oxalic ac id. The darkc o lour o f the urine s o frequently observed after the use o f carbo licac id ensues as well after the internal use as after the external applica

‘Ph il . and Med. Surg. 1872 , p . 343 .

1‘Arch . f . v, pp . 335 and 470 ; Deut. 1870, p . 341 , et seq ., 187 1,

p . z5 , et seq. Schm idt’s J clv, p. 2 72 .


tion o f the substance, and is attributed to oxidation o f pheno l in thekidneys

,but from the intensity o f c o lo ur o f the urinary secretion no

c onc lus ion can be drawn as to the saturation o f the o rganism with theremedy

,which Sal skowski thinks to be c ombined in the urine with an

alkali . The abo ve-described symptom s o f pheno l into xication are bettertests of the saturation o f the bo dy with carbo lic ac id than is the co louro f the urine .

Brom ine water form s no test o f the presence o f carbo lic ac id in theurine

,fo r it fails to detect that sub stance in the n ormal urine .

Ho ppe-Seyler found the symptom s o f pheno l into xication en suing o n

the application o f a concentrated aqueous so lution o f the agent to the

abdomen o f an imals to agree pretty c lo sely with tho se c ited by Salskowski. Hoppe

-Seyler was enabled to detec t phen o l in the blo od,liver, kidneys, and brain,

after death from its administration ,and

,abo ve

al l, in the brain in much larger quantities than in the o ther vis cera . It

would hence appear that pheno l accumulates in the central o rgans o fthe nervous system after the manner o f anaesthetics . (As carb o lic ac idis not an ac id, it is very desirable that its sc ientific name, p heno l , shouldbe substituted fo r the term carbo lic ac id—E D .)Several fatal cases o f po ison ing by c arbo lic ac id are reported

,bo th

suic idal and ac c idental . Jeffreys and Hainwo rth’x‘give details o f a case

o f suic ide in a man, aged 55 years , who swallowed from half an ounce to

an o unce o f c ommerc ial carbo lic ac id. Death resulted in fifty m inutes .A . Ogsto nf relates a case o f a man

, 45 years o f age, wh o died thirteenand a half hours after swallowing by m istake fo r spirits an ounce to

two ounces o f pheno l . After death the smell o f carbo lic ac id was

distinctly perceptible in the ventric les o f the brain, the bladder, blo o d,and o rgans generally . Z immi gives a sim ilar case

,where from one to

one and a half o unce o f the c ommercial ac id was taken in m istake fo rc ognac . Death resulted in sixty hours after swallowing the po ison .

White§ Observed dangerous effects , no t pro ving fatal, resulting fromthe app lication o f carbo lic ac id in necro s is o f the tibia .

Hydro cyanic a cid—Preyer” has published perhaps the mo st elaborate and c omplete monograph on the action s o f the above po ison everissued, and has arrived at c onc lusions the importance o f which can

scarcely b e exaggerated. A mo st valuable index of the bibliography o fthe subject is added.

Preyer divides the symptoms exhibited during the course o f a fatalcase o f po isoning by russie ac id into three stages—a prelim inarystage, befo re the animal

)

falls a c onvulsive stage, endingand a paralytic o r c omato se stage. During the first o r

stage the breathing i s rendered labo rious and the frequ

respirations diminished, whilst during tthe respirations are dim inished to an extraordinary extent . In

last,the paralytic or comato se stage, either the respirations undergo

‘Med. Times and 187 1 , i, p . 42 3 .

1‘Brit. Med. 187 1 , p . 1 16 .

I‘Virchow und Hirsch ’s Jahresb er. 1871, i, p . 337.New Y ork Med. p . 2 74.

Die Blausaure’

(pamph let).

448 REPORT ON MEDICAL JURISPRUDENC'E.

the respirations being at first retarded in frequency and then renderedmore rapid.

Preyer finds that when respiration has ceased the only availablemeans of resusc itation is artific ial resp iration . It is, o f c ourse, presuppo sed that the heart has no t also ceased to beat . Atro pine i s the on lyreal dynamic antido te to hydro cyanic a cid

,and it appears to b e a per

fect one, its phys io logical actions being in direct Oppo sition to tho se o f

the ac id. It is necessary, to ensure success , that the alkalo id shoul db e administered by subcutaneous injection very shortly after the ingestion Of the po ison, on acco unt o f the rap idity with which this acts andthe comparative slowness with which atropine i s absorbed from the

stomach . Rabbits to which atropine was administered before the useo f prussic a c id

,exhibited a surprising immunity to the action of this

m o st p owerful toxic agent .Dr. Amo ryfi

‘o f Bo ston , Massachusetts, publishes experiments illus

trating some o f the phys io logical and patho logical action s o f hydro cyan icac id. The fo llowing is a summary of his c onc lusions : Artific ialrespiration do es not prevent the intoxication o f prussic a c id, n or do esit materially assist in the elim ination o f the po ison

,c onsequently

means directed to the institution o f artificial respiratio n in cases o f po isoning by the a c id are unnecessary fo r the pro tection o f life . (2 )Artific ial resp iration will prevent the o c currence o f c onvul sions or of

the muscular spasm s which fo llow the absorption o f the po ison in a

do se Of suffic ient quantity to endanger life. (3 ) Muscular irritabilityand nervo us conductibility are n o t impaired by the into xication c aused

by hydro cyanic ac id in cases where art ific ial resp iration has been maintained until after the cessatio n o f cardiac pul sations . (4) The staticc ongestion o f the pulm onary tissue is either a po st -mo rtem symptomo r is due to the asphyxia which has been considered by some experi

menters as o ne of the causes o f death in cases o f po isoning by rus sic

acid. 5) Death by this agent is due to some o ther cause esides

a sphyxia,and it may be suggested that the fundamental cause is a

state of blo od po isoning due to some alteration o f either the physicalor the chem ical c onditio n Of the blo o d ; which o f the two it is n ot the

purp o se o f the autho r to discuss . (6) The apo plexy in the ence

phalo u and sp inal c o rd, no ticed by Tardieu as an anatom ical lesion dueto the into xication produced by this agent , is probably referable to theasphyxia, sec ondarily induced, and not to the d1rect action Of the po ison .

T he sam e c ondition has been o bserved in animals dying from asphyxiapro duced by o ther c auses , as

,fo r instance, by nitrous o xide and by

chlo rofo rm . When asphyxia i s no t present in a case o f po ison ing fromprus sic ac id no very marked apoplexy o r c ongestion is no ticed po stmo rtem .

Dr . Mialhe f endeavours to prove that ru

bine with the alkalies of the blo od, and t at

the catalytic action o f the c orpuscles fromwhich S chOnb ein has already dem onstrated as taking placered blo o d-corpuscles

,and thus oxidation in the blo od do es no tif ‘The Prac titioner, ’ viii, p . 197.

1° L’

Union Médicale,’ NO. 65 , 1872 .

ATROPINE.

Hydro cyanic ac idWould thus appear to act upon the blo od in the samemanner a s it acts upon fermenting so lutions , which immediately on theaddition o f the ac id c ease to ferment .N itro -benzo l .—Bahrdt’* describes several cases o f p o isoning with

nitro -benzo l , one o f which p ro ved fatal . Three young persons , aboutthe age o f 2 0

, prepared a liqueur by filling an o rdinary wine-bo ttle withone part of water, two parts o f alc oho l

,and, as was said

,twenty drop s

Of n itro -benzo l . One o f the boys drank largely o f the m ixture about8 O

’

clo ck in the mo rning . Death o ccurred about 5 p .m . T he symptoms

and po st-m ortem appearan ces are m inutely des cribed . T he genera lsummary is given in the fo llowing prepo sitions : ( I ) even with a fataldo se o f n itro -benzo l there is a latent perio d o f from one to two ho urs ;(2 ) this latent perio d is independent o f the kind o f preparation , o r o f

the quantity swallowed ; 3) even during the latent perio d a peculiargreyish-blue disco lo ration Of the skin is Ob served ; (4) rap id pulse,interm ittent respiration ,

unc on s cio usness com ing on gradua lly o r sud

denly , and dilatation o f the pup ils , are c onstant signs o f p o isoning withnitro -benzo l ; vomiting and c onvulsions are usually o bserved, but maybe absent . A trans itory reco very may o c cur even in fatal cases ;(5) nitro -benz o l p oiso ning differs from prussic ac id po ison ing by itslonger latent perio d, the greyish-blue c o lour o f the skin

,and the dark

brown c o lo ur o f the blo o d (6) as treatment, Bahrdt rec omm ends in

the first instance the use o f the stomach -

pump , the inhalation Of

ammonia vapour, and c op ious tran sfusion (2—3 o unces) (7) afterdeath there is a distinct sm ell o f bitter almonds ; the blo o d is darkbrown and fluid

,and the endem ic rigidity is well prono unced and o f

lo ng duration .

Chlora l hydra te—Several cases Of po isoning by chloral have been

repo rted in the m edical j ournals at hom e and abro ad. As m o sto f the cases are in E nglish j ournals and easily ac cessible, wemerely givethe referen ces .See o n this subject the papers by B . W . Richards ond

’ Hunt andWVatkins

,IN o rris , § Fuller, ” Shawfi]and Burr.

” Mas chkafl‘

rep orts acase in which , after the admin istratio n o f a drachm Of ch loral hydrate

dentist fo r the purpo ses Of anaesthesia during the extraction Ofteeth,

h resulted within a few m inutes a fter the o peration .

trop ine.

—Pro f. H . C .Wo o d,jun .,l;I o f Pennsylvania, has c onfirm ed

Observations Of Messrs . Wharton Jones and Lemattre, that bellaOr n o influence on the pup ils o f p igeonsthat belladonna , stram o nium ,

and hyo sresemble m o rphine in their want o f actio n on these birds . It

pears to be almo st imp o ssible t o imm ediately kill them with the

if ‘Arch . f . Heilk 1871 , p . 3 2 0 .

1‘ ‘Med . Times and 187 1 , i, p . 169.

I‘Brit. Med . 187 1 , i, p . 193 .

‘Lancet, ’ 187 1, i, p . 2 2 6.

Ib id., 187 1, i, p . 403 .

1T Ph il . Med. and Surg. July, 187 1 .

Ib id . , Dec ., 187 1 .

H’ W ien . Med . 187 1 , NO . 48.

If‘Mner. Journ. Med. lxi, p . 1 28.

450 REPORT ON MEDICAL fiIRISPRIlDENCE.

extracts given by themouth . Three grains o fpure sulphate Of atropinewere given to a p igeon ,

and retained, and yet the do se did no t appear to

interfere materially with the wellbeing o f the bird. It is very p o ss ible,however, to kill the birds with the po is on by enorm ous do ses hypodermical ly in

'

ected. These experiments sh ow what c are mus t be

exerc ised in rawing c onc lusions in to xico logical research from physiological investigation s . Dogs will bear alm o st hero ic do ses o f atro p ine,and the horse wil l to lerate with impunity an eno rm ous do se o f strychninefif Hence conc lus ions as to the antido tal or non -antido tal effec tso f two po isons on the human subject canno t be drawn with certaintyfrom experiments on the lower animals .Tobacco .

—Drs . Vohl and E ulenbergf have published an elaborate ex

perimental es say on the to xic o logical relations o f tobac c o , with espec ialreferen c e to the chem ical c onstituents o f to bac co sm o ke. After an

a cc ount o f the intro duction o f tobac c o into E urope, a summary is giveno f its chem ical histo ry, and the statement is made that the na rc o ticaction o f tobac c o has been attributed to nico tine in error . The authorsadduce analyses and experiments o f their own in supp ort o f this view .

Stres s is laid upon the fac t that s ome fo rm s o f tobac c o which pro duceIn snuff this

bac c o c ontained a m ere trace

at all ; hence nic o tine intoxithese sorts o f the weed . ThOf strong to bac c o c ontaining so much a s 4 per cent .tobac c o being burnt b o th in pipes and a s c igars . T he

were fo und to c o nsist o f o xygen ,nitrogen,

marsh gas ,c arbonic a c id, en . T he sm oke

a c ids thus ab s o

exam ined. T h

hydride (CIQHthe fatty ac idscinic ac id, andIn the ac id so lution were found amm onia and ethylam ine

the fo llowing hom o logous bases z—Pyridine, C5H5N ; p ic o line,

lutidine, C7H9N c o llidine, CSHHNQ ; parvo line, - C

QH13N ;

CIOHl ; rubidine, Cq 7

N ; and, perhap s , viridine, CIQHIQNtrace o f nico tine c o uld be detec ted.

The authors ascribe to the p ridine bases,and

only the nausea and o ther un ea sant sympt om ssons beginning to sm oke, but a s o the m o re chroui

Odour and in physio logicalthis alkalo id

,but they differ essentia lly in their respec tive bo iling p o

T he well-known fact that a much stro nger to bac c o can be smokedimpunity in c igars than in a p ipe is explained thus . T he smokepipe c ontains much m ore vo latile bases than that o f a c igar, and

‘Amer. Journ . Med. lxi, p . 3 77 .

1‘ Vrtljhrsscrft. f. Gericht. N. F. xiv, p . 249 .


c itrate) . 5) The physio logical action Of tobacco smoke is, to a greatextent

,due to the n ic o tine it c ontains .

Op ium—Dr. S chaefer, * o f Dusseldorf, publishes a case o f opium

p o isoning o f c onsiderable interest,—that o f a child»which died aftertaking about three quarters o f a gra in o f o pium in two do ses . The

p ost-mortem appearances were unusually well m arked. On sawing

through the calvarium there was a flow o f black, fluid blo od the blo o dvessels o f the dura mater

,but m ore espec ially th o se o f the arachno id,

b o th on the cerebral c o nvo lutions,the c erebellum ,

and the medul la

o blongata, were filled with blo od and there was likewise fo und in bo thventric les

,no t only a c ons iderable quantity o f efl

‘

used serum ,but also

several drachms o f a sim ilar fluid were met with at the base o f the

brain . Death from apoplexy was m o st markedly indicated. Besidesthe m ore o rdinary appearances met with on sec tion after o piumpo isoning, Schaefer describes in this case a sp ongy condition o f the

lungs, which were gorged with black , fluid blo od, blo od in all the

cavities o f the heart ; hyperaemia o f the liver and spleen, and a fullurinary bladder. The appearances presented by the po st-m ortemecchymo ses were very striking ; instead of being purple they were ro sered and o f great extent .The presence o f o pium was ascertained by analysis in the oesophagus,stomach , and its contents

,and in a portion o f the small intestine,

although the who le quantity o f m o rphia taken c ould no t have exceededone tenth o f a grain . The opium was adm inistered, o ne half five ho urs,and the remainder three hours, before death .

P icrotoxin .

—Herr Po vergOT has investigated the action o f picro

toxin on the reflex inhibito ry c entres o f the brain o f frogs , and arrivedat the c onc lusion that picro to xin and strychine act in a similar manneron these centres .

been suppo sed to result fromon the zinc vessels in which the ice is generally manufac tured.

Mushro oms—C . Ruckert§extracting from the plant byan alkalo id—mus carine. Ru

sulphate from a thick extract Ofless , syrupy substance, tasteless , and Odourless . Ireactions o f an alkalo id, and is no t c o loured eitheralone, o r by this in c onjunction with o xidising agents .T he physio logical effects o f muscarine are stated to be antagonis

to tho se of atropine.

i“ ‘Vrtljhrsschrft. f. Gericht. Med N . F. xvi, p . 2 551' Deut. Ztschr. f . d. Staatsarznyk ,

’xxix, p . 1 .

1 Deutsch . Arch iv f . Kl in . ix, p . 303.

‘New Rep . xxi, p . 193 .

MUSSELS . 45 3

Husemanni“ publishes a paper on the po isonous action o f fungi ,embrac ing all that is known on the subject

,but embodying no new

remarks .Snake p o isons

—The medical pro fession is greatly indebted to Dr.

Fayrer'

l' for his magn ificent work on Indian snakes . It embraces the

who le range o f the subject,beginning with c o lo ured lithographs and

anatom ical des criptions o f vario us snakes , fo llowed by an experimentalinquiry into the reputed cures fo r their bites . The p o ison of the c obrais the m o st deadly o f al l . Dr . Fayrer says that it is m o st deadlyin warm weather ; that it seem s to act through the c irculation

,

and kills by some o ccult influence—whatever that may m ean—on the

nervous system . He distinctly lays it down that the po ison is capable o f

being absorbed through themu c ous membranes,though , Of c ourse, much

less rap idly than from an o pen wound or through the sero us membranes .As the po ison kills when intro duced into the stomach there is a c ertainamount o f risk attending the act o f sucking a wound inflamed by apo isonous snake . The venom Of the c o bra kills every living creature

,

except the co bra itself, and, perhaps , some o ther deadly snakes .Dr. Fayrer has tried, perhaps , every known reputed remedy for thetreatment o f po isonous snake bites , and always unsuccessfully . The

lightning-like rapidity with which the ven om diffuses into the blo o dho lds out little hopes Of any remedy being applied with suc ces s .

E ven immediate ligature and amputation , as appeared from experimentsup on animals

,is o f little avail . Am ong the remedies used we may

enumerate, ligatures , amputations, Aristo lo chia indica , carbo lic ac id,

liquor amm onise injected into the blo o d, liquo r po tassse, Co ndy ’s fluid,eau de luce, brandy, and o ther stimulants, the Cape antido te

,

norbish,quinine

,ipecacuanha, various secret no strums , as the Tanj ore

pill, &c . There appears , then,to b e no known antido te to the po ison

o f the deadly Indian snakes, and it is probable that the o nly suc cessfultreatment (suc cessful only in rare cases) is amputation o r exc ision

,

the application Of ligatures , the ac tual cautery o r burn ing by strong ac ids ,and the use o f stimulants internally .

Dr. Fayrer is o f Opinion that the m o st suc cessful means for stayingthe lamentable lo ss o f life n ow go ing on in India from the bites o f

these venom ous reptiles is the Offering o f suffic ient pecuniary rewardsto the natives for the destruction o f venomous snakes . In 1869 , o ut

o f a population o f I 2 0,9 72 ,2 63 , persons died from the effects

o f snake bites , an annual rate o f m ortality Of per 1000 personslivinSrizahe p o ison—Mr. Vinc ent Richardsi asserts that the p o ison o f

venomous snakes may be abs orbed by mucous and serous surfaces , andeven by the skin . This o p inion is supported by the autho rity o f

Dr . Fayrer, who Observes, that the po ison is deadly when ap plied to a

mucous o r serous membrane, to the stomach , o r the c onjunctiva .

P o isonous mussels—M . de Beunie§ attributes the o ccasional poi‘9 Schm idt’s Jahrhu cher,’ Cxlix, p . 89 , and cl , p . 89 .

1‘ The Thanotophidia of India .

’By J . Fayrer, M.D. London, 1872 .

I‘Med. Ann . o f Med. xxix, 162 .

Journ. de Pharm . et 1871, p. 298.


s o nous qualities of the edible mussel (Mytilus edulis) to their feeding onthe spawn o f star fishes . Star fishes spawn in the m onths OfApril, May,July, and August, and it is chiefly in these m onths that mus sels exh ibitpo is onous pro perties . He states that the spawn o f the star-fish po sses sesa very irritant action,

and that the slightest c ontact with it causes vio lentitching, and may even o ccasion inflammation resulting in gangrene .

The fo llowing no tes relate to the detection o f p o isons .P ho spho rus

—M . Poulet’x‘ gives a very s imple method o f detectingthis p o ison when being excreted in the urine

,in which it appears as

hypopho spho rous ac id. The urine is c alc ined after the addition o f

n itric ac id ; when ,as the liquid appro aches the state o f dryness, the

m ixture suddenly Catches fire and burn s with a peculiar kind Of

deflagration . This test must,however, b e liable to many fallac ies ;

deflagration alone in the presence o f n itric ac id c anno t be regarded

c onc lus ive evidence o f the presence o f a lower oxide o f pho spho rus .Dalm on

'

l' describes a new reaction fo r pho sphorus . A stream o f

hydrogen is passed through the o rganic substan ce suppo sed to c ontainpho sphorus ; and the is suing gas i s ignited, and a narrow glass tubeInverted o ver the flame when detonation s

,ac c ompanied by a peculiar

lum ino us appearance, will be Observed. With care, and b a peculiarartifice , a beautiful green ring Of flame m ay be obtained. f the interio r o f the tube be previo usly m o istened W1th distilled water, and afterthe abo ve experiment with a so lution o f nitrate Of silver

, a brown precip itate, speedily bec om ing black , will be Observed. NO p latinum tip for

burning the gas i s required.

Neubaueri also describes an impro ved and s imple m etho d of

Obtaining Mitscherlich ’s T he matter to be

tested is distill ed in an O

which passes a glas s tubevertical limb o f which hastillation

,the substance to

giving a blackreaction o c curs with sulphate o f c opper as

do es no t blacken lead salts as sulphuretted hydrogen do es .Hydro anic a cid.

—Almen § p o ints out

metho d o

c

fyapplying the sulpho cyan ogen test fo r the detection o f

cyanic ac id. When the suspected so lution, o r rather a po rtion dOff from it, i s treated with amm onium sulphide and evapo rated

Gaz . Med. de Paris, ’ 1872 , p . 400 .

1 Ztschr. f. Anal . 187 1 , p . 132 .

I Ib id . , p . 2 54 .

Neu. Jahrb . d . xxxi, p, 2 26.


o f ether. The residue is ac idified and again shaken with ether, whenthe p icro to xin is dis so lved o ut, and may b e Obtained by evapo rating theethereal liquid. The ma s s is dried and redis s o lved in alc oho l faintlya c idulated with acetic ac id, and the filtered s o lution evapo rated. If

n o dis tinc t crystals are Obtained the res idue is to b e recrystallised froma lc o ho l . Picro toxin as thus Obtained is rec ognised by the fan -like o rwheatsheaf fo rm in wh ich it crystallises , its very sparing s o lubility in waterand ether, its ready s o lubility in a lcoh o l

,its b itternes s, and its ac tion

o n fishes . A c ouple o f fishes o f about seven ounces weight are p lacedin ra ther les s than two quarts o f water . A so lution Of the crystals

,

o b tained as abo ve,is m ade by diss o lving them in alc oho l , adding water,

and b o iling Off m o st o f the alco ho l . This s o lution is then added to the

water c onta ining the fishes . The fishes speedily die if the suspectedsubstance b e p icro to xin . Lupuline has no t this po iso nous action on fishes .Thirty gra ins o f c o c c ulus indicus, c o rresponding to o ne and a half grainp icro to xin ,

is suffic ient to kill a fish o f seven to eleven po unds ’ weightin ten ho urs . At leas t five quarts o f beer should be Operated on .

Depairefi“ in a no tice on the abo ve paper, gives ano ther pro ces s fo r

separating picro to xin . T he beer is shaken with c omm on salt—400grains per quart—and filtered. The filtrate is exhausted twice w ithether the residue from the evaporation Of the ethereal s o lutiondis s o lved in alc oho l

,half an ounce Of water, and o ne drop o f sulphuric

a c id added to the so lution , the liquid heated fo r a quarter of an hour onthe water-bath , co o led, filtered, and shaken with ether, the etherealso lution i s evapo rated, the residue recrystallised from alc oho l and

examined.

The Wharton-Ketchum Tria lf l'

This celebrated trial has exc ited so much interest throughout theU nited States , and the nature o f the evidence Offered is s o remarkable ,that we are induced to Offer a summary o f the sc ientific testimony alongwith a brief histo ry o f the case . The theory o f the pro secution wasthat Mrs . Wharton was in debt to General Ketchum

,and had invited

him to her h o use fo r the purpo se o f po is o ning him , and that sheactually accomp lished her des ign by m eans Of tartar emetic . T he

trial lasted fifty-two days , and the jury were lo cked up fo r seven weeks .Co llateral evidence was o ffered to s how that she had als o attempted top o is on a Mr . V an Ness

,c onnected with her firm o f bankers , who was

staying in her ho use at the same time as G en . Ketchum .

G eneral Ketchum ,the deceased, was an o ld army oflicer, an intimate

friend o f the a ccused. He was in apparently go o d health and o f a ctivehabits . On June 2 4, 187 1 , a very hot, sultry day, he had undergonec onsiderable bo dily exerc ise by walking in Wash ington on businessmatters . He neglec ted eating his dinner, p arto o k p lentifull o f icedwater

,to o k the train fo r Baltimo re, and arrived at Mrs . harton

’

s

ho use between 6 and 7 p .m . He ate very heartily at supper about 9p .m . He retired, apparently in go o d health , at 1 1 p .m .

, but had to go

to the c lo set once or twice in the c o urse Of the night . Next mo rning heLo c . c it.

T‘Amer, Journ. of Med. Sc ,

’ lxiii, p. 329.

wnARTON-KETOI-IUM TRIAL. 45 7

remarked that he had no t been very well in the night, but he went out,and parto ok o f all his m eals with the family on that day ; and althoughc omp laining o f n o t feeling well, he appeared mo re cheerful after tea

,

chatting with the fam ily and sm oking until he retired at 1 1 p .m . Beforego ing to bed he drank a glass o f lemonade with a Mrs . Chubb . His

glas s c ontained s ome brandy, which he himself added. On that nighthe was again sick , and had slight purging . On the morning o f the

2 6th he c omplained o f sickness and giddiness , and rema ined in hisro om during the day, although he ate a ll his m eals . In the aftern o on

,

at the so lic itation o f the a ccused, he saw Dr . W illiams . At 4 p .m . thatphysic ian found him sitting up and vom iting into a vessel which heheld. Dr. William s o rdered him to bed

,and prescribed creaso te and

lime-water, thinking him to be sufi'

ering from cho lera m o rbus . NO

mention is made o f diarrhoea at this time . Next m orning he had muchimpro ved

,and he dism issed his physic ian , the latter regarding his

patient as well .Throughout this day, however, he was somewhat drowsy, as if under

the influence o f some narco tic . He stated that he had taken some o f

his own m edic ine,and a vial which had c ontained laudanum was found

beneath his bed . On June 2 7th he appears neither to have vom itednor been purged, but on the m orn ing o f the 2 8th he was found on a

so fa nearly insensible . At 1 0 p .m . Dr. W illiam s found him in a sem ic om ato se state, very diffi cult to arouse, and giving inarticulate an swers .On being touched a slight c onvuls ive tremor passed over him from headto fo ot . His head and face were much c ongested, o f a purp lish tinge .

His limbs were rigid. He gave only muttered rep lies to questions, anddid no t c omplain o f suffering. The respirations were normal , the skinwas no t preternaturally m o ist

, the pupils were no t c ontracted, but wereinsensible to light . The treatment c onsisted o f ice to the head, and

40 drops o f tinct . Ofgels eminum in water. This was to be repeated in 2

hours . Whilst the ice was upon the head, he had some convulsions o fa peculiar character

,the tendency o f which was to throw the body

from the back to the left side. At 1 p .m .,after a third do se o f gel

seminum,the general became very restless , and uttered incoherent cries .

The c onvuls ion s increased in intensity, giving to the bo dy the truecharacter o f o pistho tono s . He tore at his neck and abdomen

,s o as to

inflict extensive abrasions but it is doubtful whether these m o vementswere no t automatic . At Dr . William s adm in istered chlorofo rm ,

and drew Off the urine, suspecting uraem ic po isoning, but detected noalbumen . Thirty grains o f chloral hydrate were given in m ilk, butthe c onvulsions were so vio lent that he hit the Spo on so that his firstto oth was lo o sened. At 3 p .m . he died in a c onvuls ion .

The autopsy was made next day by Dr.William s, assisted by Prof.Miles and Chew . The brain and abdom inal cavity only were exam ined.

No thing was disc overed to acc ount fo r death , the only thing no tedbeing red punctiform c ongestion o f the cerebral lobes, and doubtful

canal . The stomach was se

458 REPORT ON MEDHJAL JURISPRUDENCE .

at least twenty grains . His metho d o f arriving at this c onclusion iscurious and open to much o bjection ; nevertheles s , it has great influence in fo rm ing the p robable ground of the Op in io n ,

expres sed at the

trial,o f Dr . W i lliam s and o f Pro fs . Chew, Miles , Donalds on ,

Howard,

JOhnstone and Sm ith,that the death was no t due to natural causes .

Dr. Aikin s analys is o f the c ontents o f the stomach was c onductedthus . Inferring the po ssible existence o f strychnine o r o f arsenic , hetested fo r the fo rmer o f these by the pro ces s o f Stas , which gave him ,

he says,negative results . He appears, however, to have o mitted apply

ing the c o lour andphysio logical tests . He next pro ceeded to exam inefor arsenic and antim ony

,using the material already employed In the

analysis fo r strychn ine. A po rtion o f this material was treated withhydro chloric ac id and chlo rate Of p o tassium ,

then,without previous

treatment with a sulphite, a s tream o f sulphuretted hydrogen was p assed.

through the so lutio n . A dark brownish prec ipitate was thus Obtained.

As this prec ip itate did no t disso lve In amm onia, he was satisfied that itc ould no t be arsenical . Ano ther portion was now treatedwith tartaricac id and sulphuretted hydrogen, without prelim inary destruc tion o f

o rgan ic m atter, when a reddish-brown o r brown ish-red prec ipitate wasObtained. When this was s e arated and dried it disso lved In hydrochloric ac id ; this so lution, w en dr opped into the water, gave a whiteprec ipitate ,

that white prec ipitate became o range red when treatedwith sulphide o f ammonium ,

and it wascompleted all that was necessary to sat

Of antimony, and he stated in evidencewould have produced these results exceptRein s ch ’s test had failed to give any res

tirely neglec ted to attempt to pro curestomach . His method o f determiningpresent was simp ly a piece o fgues swork .

defence dem onstrated that the co lo ur tewith all its subsequent reactions , save on

antimony was present .B loodstains .

F . L . Sonnenschein il‘ prop o ses a new reagent foro f these, viz . so luble tungstates, which give, withgelatine, a prec ip itate inso luble in ac ids . So diumsaturated with either acetic o r norfo rms evet10n . A

ture having the same intensity o f c o

treated with amm onia . On acidificati

appears . The prec ipitate contains allcineration and fusion o f the a shes with

a Vrtljhrssch . f. Gericht. N.F., xvi. p . 263


E cchymoses afl er sufi‘b cation.

—Dr . Julius Lukom sky,*Of Kiev, pub

lishes an interesting critic ism on the ec chym o ses which Tardieu hasdes cribed as characteristic o f death from suffo cation . In o rder to arriveat a satisfacto ry settlem ent o f the questio n s at issue, Dr. Luk omskym ade an elab o rate series o f exp eriments on the pressure o f the blo o d inthe various vessels during the time that animals were being suffo cated.

By suffo cation (erstickung) is meant,in a restricted sense, all causes o f

death by m echan ical app lications fo r the purpo se o f exc luding air,ap

plied to the m outh and no se,to the air passages and oeso phagus , pres

sure on the chest and abdomen ,and suffo cations by being buried in

earth, o r in any pulverulent material .During suffo cation it wa s fo und that b oth the arterial and venouspressures werematerially increased. After this had been established beyo nd doubt, the variation s in respiration were n o ted—1 st

,after s imple

c lo sing of the trachea s o as to produce suffo cation ; 2 nd, after suffo ca

tion induced by irritation o f the nerves ; 3rd, after suffo cation c onse

quent on section o f the nerves 4th , by o c c lusion o f the trachea afterfo rcing air into the lungs under increased pressure 5th , in suffo cationby rarefa ction o f the air. It was thus pro ved, on comparing the pres sureo f the blo od and the variations in the mechanism o f resp iration duringsuffo cation

,that during suffo cation a typic al change in the rhythm o f

resp iratio n takes place (2 ) a c onsiderable increase of pres sure was no tedin b o th arteries and veins

,espec ially in the regio n o f the thorax ; 3)

there was a diminution o f pressure in the pulm onary artery ; (4) thegreatest increase in the pres sure o f the blo od c o inc ided with the periodo f m o st powerful respiratory effort, i. e. with expiration . Dogs werethe animals experimented on .

T he c onnection between the arterial and venous pressure and Tardieu’ s ec chymo s is is next traced. In no rmal respiration , during inspiration,

there is an increased flow o f blo od into the right heart, a

quickened action o f the heart, and consequently an increased arterialpressure ; whilst during exp iration the c onverse Obtains . But in

suffo cation the greater effo rt at and duration Of each inspiration increases the flow o f blo od to the right ventric le . In c o nsequence o f a

dim inution o f pressure in the pulm onary artery , blo o d flows mo re

quickly from the right into the left ventric le, and c o nsequently bo ththe activity o f this and the pressure in the arteries are heightened.

But when a rapid and energetic expiratory effo rt fo llows upon the

c limax of in spiration, and this effort at expiration adds an increase ofpressure to the already heightened arterial pressure in the tho rax, it isseen that there is a direct c onnec tion between the altered relation

the develOpmen

duced by various means,as

,e .g .

,by section o f nerves ;

rim ents , valuable a s they :are, are o f mo re interest tothan to the medical jurist .

if Vrtljhrsschrft f. Gericht. N. F., xv, p. 58.

R E P O R T

MATER IA MED I CA AND GENERAL

THE RAP EUT I C S .

THOMAS STEVENSON,M .D. Lom

,

Sugolzovinate of sodimn.

-M . Rabuteau* propo ses the use o f this saltas a purgative, and states that it po s sesses the fo llowing advantages .Its taste is very slight at first, and is afterwards sweet, s o that itis taken without difficulty even by ch ildren . It is the m ildes t inits ac tion o f all the saline purgatives , and is especially useful in c o lic .

It pro duces no pain or to rm ina, and is exc lus ively a dialytic purgative hence it is useful during menstruation and pregnancy . Itpresents all the advantages , and n one o f the disadvantages , attendingthe use o f c itrate o f magnes ium . In the first place, the sulpho vinate ism o re agreeable to take, espec ially when adm inistered in seltzer water

,

than the c itrate ; and in the next place, it do es n o t tend to the pro duction o f calculi, as the c itrate of magnesium is apt to do . Sulphovinate o f so dium acts as a purgative when given in relatively smalldo ses . Rather less than an oun ce o f the salt disso lved in seltzer wateris invariably sufiicient to produce in an adult five o r six sto o ls .25 drachm s suffice fo r a child, and this do se pro duces very apprec iableeffects even in an adult . It do es no t pro duce after-c onstipatio n ,

as saline purgatives are s o apt to do this owing to the rapidity withwhich the sulpho vinate o f s o dium is elim inated after its ab s o rption .

P eroxide of hydrogen.-Dr . John Day ? o f Geelong, finds in pessaries

c ontaining pero xide o f hydrogen a c onvenient m etho d Of destroyingthe Offens ive o dour which ac c ompan ies the discharges o f patients suffering from cancer o f the uterus . The fo llowing is his fo rmulaMelt, with gentle heat, twelve drachm s o f c o c o a -butter, and well stirin until thoroughly incorporated eight scruples o f

.

ethereal so lution o fperoxide o f hydrogen . When nearly co ld divide into eight pessaries .

One to be inserted into the vagina every night andmorning, o r oftenerif necessary . They keep well .

3“ ‘Gaz . Kebd June 10, 1870 .

‘Austr. Med. 1871, p . 303.

462 REPORT ON MATERLA MEDICA, ETO.

0hlorides .

-Rabuteau* has fo und that c ommon salt, when given inconsiderable quantities, greatly increases tis sue change and the excretiono f urea . At the same time it in c rea ses the secretion o f gastric juiceand its ac idity . On th is ac c o unt animals which get much salt digesttheir fo od well , but do n o t get fat . T he red blo o d-c o rpusc les becomem ore num erous when salt is taken ,

and this , alo ng ,

with its o ther properties , wil l render it useful in phth is is and diabetes . Very large do seso f salt are purgative . Salt fo od produces c on stipation , because the saltis ab sorbed into the blo od, and lessens the exo sm o sis into the intestines .Small do ses o f salt are, therefo re , very serviceable in diarrhoea and

dysentery, when o ther remedies fail .Chloride o f amm onium acts as a diuretic , increases the excretion o f

urea, quickens the pulse, and seem s to ra ise the temperature . It do esno t impair digestion . It is no t diapho retic . Large do ses inducevom iting, and c ause tempo rary weaknes s o f the lower extrem ities . Sal

ammonia c alo ne has a spec ific remedial ac tion in bron chia l catarrh ;but all amm onium c ompounds increase expecto ration .

Chlo ride o f p o tassium increases the excretion o f urea,but has only a

slight diuretic ac tion . It increases the appetite , and causes s light c onstipation . It slows the heart, and Rabuteau thinks this salt m ight beused in stead o f digitalis .Chloride o f magnes ium ,

injected in large do ses into the veins , slowsthe heart like chlo ride o f po tas sium . Two and a half drachm s pro ducespurgation ,

no t ac c ompanied by c o licky pains , and no t suc ceeded byc onstipatio n . It is also pleasanter to take than the sulphate o f magnesium

,and Rabuteau,

therefo re, rec ommends it in place o f the lattersalt, in do ses o f 7 drachm s fo r men, 5% drachms fo rwomen , and half ano unce fo r children . The do se should be dis so lved in a c onsiderablequantity o f water.

Ferro us chlo ride do es no t c o agulate either egg o r serum -albumen,

and hinders the c o agulation Of blo o d. One grain injected directly in tothe c irculation sto ps the heart like po tassium chlo ride . The blo odremains fluid. Ferrous chloride i s chiefly excreted by the intestine .

Ferric chlo ride is reduced by a lbuminous substances, and undergo esreduc tio n in the b ody . It is uickly abso rbed. Rabuteau rec ommendsthe employment o f ferro us chlo ride in medic ine, and he finds that reduced iron

,ferric o xide, and ferrous carbonate are c onverted into

ferrous chlo ride in the stomach .

G o ld and palladium chlorides are reduced in the body, and whengiven fo r a lo ng time pro duce album inuria and renal affec tion . Theautho r c onsiders that there is a particular kind o f album inuria produced by metals , as albumen appears in the urine in po ison ing by lead,nitrate o f s ilver, and the salts o f uranium and cadmium .

B romides .-Wo od1

' finds that, by c ombining brom ide o f po tassiumwith tinc ture o f cannabis indica, the do se o f brom ide may be raised toa drachm and a ha lf three times a day without any bad effect fo llowing.

The brom ide in do ses Of one drac hm frequently causes melancho lywhen given alone . Daco sta thinks that if 40 to 60 grains o f bromide

Union Médicale,’ lxxii i, p . 1 50 et seq ., Comp . lxxiii, 24, p . 1390 .

1' ‘Brit. Med. Oct. 14,

187 1, 435 .

464 REPORT ON MATERIA MEDICA, ETc .

brandy . The effects o f bo th Of these are the same in many respects .They quicken the heart and dilate the vessels . There was no distinctalteratio n in temperature in the axilla o r rectum ,

nor any change inthe excretion o f nitrogen o r pho sphates either in the urine o r faeces .They do no t c onsider the dietetic eflb cts o f c laret to be the same as tho seo f brandy and water, but the diflerences c ould n o t b e disc o vered by themethod o f experimentation they emp loyed. T en o unces o f c laret c ontaining about one fluid ounce o f pure alc o ho l caused n o unpleasant heato r flushing. Twenty ounces pro duced b o th . Alcoh o l began to appear

in the urine. T he autho rs c o ns ider that the use o f alc oho l by healthypers on s is unnecessary and m ay be injurious .Bouvieri found that when fever was pro duced in animals by the in

jection o f putrid matters, tho se which were treatedwith alc oho l resistedthe fever much longer than o thers . Their temperature c ould b e reducedseveral degrees by the adm inistratio n o f alcoho l . He Obtained go o dresults from the use o f al c oho l in typhu s , but no t in interm ittent fever .

Rab owf found that wine and brandy,in do ses o f two o r three table

spo onfuls , increased the temperature in 2 3 ca ses, and left it unchangedin 2 . T he rise was generally Fahr.

, but o ften only Fahr .

A rise o f temperature was also n o ticed during c o llapse, when the adm inistration of wine was attended with much benefit .Manizu i and Fokker § found little change in the temperature o f thehuman bo dy after the m o derate use of alc oho l , but Fo kker o bserved a

slight fall in a dog. It s om ewhat dim in ished the excretion o f urea in

the dog, and the effect o f a given quantity was the same whether it weregiven in repeated small do ses o r in o ne large one . Fokker regards itas fo od, and indicated in all diseases where there is danger o f deathfrom inanition . He do es no t c o ns ider it to act a s a febrifuge .

Danet gives several cases showing that the m ortality in pneumoniai s least when patients are treated with alc oh o l and bl isters

, greaterwithdigitalis and blisters, and greatest with antimonials and blisters . He

has also seen benefit from the use o f alc oho l in c ongestion o f the lungs,

and mentions the benefic ial effec ts o f its lo cal app lication in cases o fpurulent infec tion .

Subb o tinfll finds , from experiments o n rabbits,that a considerable

quantity o f alc oho l is elim inated by the skin and lungs in the first fivehours after its intro ductio n into the b o dy . Twice as much alc oho l iseliminated by the skin and lungs as by the kidneys . This result is indirec t Opp o s ition to the statement o f Lallemand

,Perrin

,and Duroy

,

that alc oho l is excreted chiefly by the kidneys . Part o f the alcoho lprobably undergo es c ombustio n in the bo dy .

Chlora l hydrate—Dr . A . Monti“ =

c ontributes a paper on the employment Of chloral hydrate in the diseases o f children . This Ob serverno ted that in children , when the do se was prop ortioned to their age,

4? Centralb latt f. d . Med. p . 80 1 .

1 Berl . Klin . 187 1 , NO . 2 2 , p . 2 5 7.

I‘Diss. 1870,

‘Virch ow and Hirs ch ’ s J 1871, p . 3 24 .

‘Virch ow and Hirsch ’s J 187 1, p . 3 2 4 .

‘Gaz . des 187 1 , 4 18, 4 2 1‘Ztschr. f. Bio log ie, ’ V1) , p . 361.

if Zeitsch . f. Bio logie, ’ vii, p . 36 1 .

‘Jahrb . f. v, p . 63 .

ANAESTHETICS . 465

within an hour and a half there supervened slight sufl'usion Of the

c ountenance and a quasi-intoxicated state, passing into sound sleep .

The pulse, which at first was somewhat quickened, was afterwards retarded, the respirations were unaffected

,and the tem perature o f the

body sank . It was only after very large do ses o f the hydrate that thenumbness o f the skin ,

fo llowed by anaesthesia,was preceded by exc ite

ment and c ontrac tion Of the pup i ls . The sleep induced is quite normal,

and on awaken ing there is neither headache no r cerebral c ongestion,no r any o ther disturbance Of fun ction . Chlo ral hydrate sometimes induces vom iting, but never diarrhoea . The do se is r to 4 grains for a

new-bo rn infant up to one year, I }; to 5 grains ; from one to five years,3 to I O grains ; and fo r children from five to twelve years o f age, from8 to 18 grains . T O infants at the breast I grain was given every fifteeno r thirty m inutes, till the desired result was o btained. His c onc lusionsare summarised as fo llows —Sleep is as readily induced by chloralhydrate in children as in adults . In symptomatic as well as in idiOpathic convulsion s it acts symptomatically, and is c ontra- indicated onlywhere there is inflammatory disease of the bronchi

,lungs , o r heart, and

the remedy must b e used with caution where the ch ild is anaem ic o r

atrOphic . Chlo ral is useful in laryngismus stridulus, chorea, and ho oping

-c ough , except in the third stage o f this last, when it acts prejudicially by checking expecto ration . It pro ved useless as an anaesthetic insurgical operations and in idiopathic and traumatic tetanus .Husemann c ontributes a long and able résum é of all that is known

regarding the pharmac o logical and toxic o logical relations o f chlo ralhydrate. A va st am ount o f literature has been laid under contributionfor the preparation o f his m onograph .

Anwatfietics .—Kohler1' reviews all the recent work that has been done

with anaesthetic s . His memo ir is a valuable one,and is enriched with

cuts o f the various fo rms o f apparatus that have been designed for theinhalation o f anaesthetic s .Byass on and Fo llet j: have c ompared the action of trichloracetate of

sodium , chlo ral, and chloroform . The effect o ftricloracetate of so dium ismore like that o f chloroform than of chloral . Chlo roform given byinhalation is the m o st p owerful anaesthetic , but when given sub cuta

neously it has less ac tion than either o f the o ther two . Chloral,when

given by the stomach,is a more powerful sop o rific than the o thers

, but

has less anaesthetic power than chlo roform .

The authors distinguish three degrees o f action in chloral . In the

first,it acts as a slight soporific and sedative o f the sensory nervous

system . This effec t is o ften accompanied by agitation like that o ccurring during unpleasant dream s . In the sec ond, it has a powerful soporific action

,les sen s sensibility c onsiderably, and produces calm and

deep sleep . This may b e kept up fo r a considerable time,without

danger, by giving a fresh do se when the effect o f one is passing o ff. Inthe third, it produces c omp lete anaesthesia, entire lo ss of general sensibility, and muscular relaxation . Death alm o st always o ccurs after

” t Schm idt’s J c li, p . 8 1 .

1” Ib id., p . 193 .

I‘Journ . de l

’Anat. et de 1870, p . 5 70.

466 REPORT ON MATERIA MEDICA, ETC.

this stage has been reached. It may sometimes be averted by artificialrespiration or inhalation o f ox gen .

Broma l hydrate—Berti an Namias* have investigated the thera

peutical properties o f this prop o sed remedy, and arrive at the fo llowingc onc lus ions . 1 . E ven in small do ses, and well diluted, bromal hydratepro duces burning pain in the thro at , pyro s is , vom iting, and

'

diarrhoea .

2 . In an emulsion ( 1 to 300) its use is barely supp ortable . E ven afterlong and cautious administration it pro duces vomiting and purgation .

3 . In relatively large do ses it do es n o t induce sleep , o r abate restlessness . It is useless in epilepsy . 4 . Subcutaneous ly injected it exc iteslo cal inflammation , and exerc ises little action in the nervo us system .

5 . Rubbed up with an equal quantity o f fatty matter, and appliedlo cally

,it produces erythema o f the skin, but it is no t s o safe an appl i

cation as a sinapism . 6 . Bromal hydrate o ffers no advantages as atherapeutic remedy o ver o ther safer and speedier remedies . 7 . To xicdo ses induce stup or, paralysis o f m o tion and sensation , and rapid o r

sudden c essation of the respiratory m o vements,ending in death .

Croton chlora l .—Liebreicht finds that cro ton chlo ral produces in animals , first, anaesthesia of the head, then lo ss o f reflex mo vements thro ugho ut the body, and, finally, death by paralysis o f the medulla o blongata. In

man it pro duces anaesthesia of the fifth nerve, while the sensibil ity o fthe bo dy and the pulse and res iration remain unaffected. He c on

siders that it is split up in the b o od into fo rm ic ether.

Byassoni sup o ses that the ac tion o f chlo ral is partly due to the

form ic ac id,whic it yields along with chlo ro fo rm when dec ompo sed in

the blo od. This suppo sition he has c onfirmed by the adm inistration o f

form ic ether, which also yields fo rm ic acid in the blo o d. Whengiven to animals , either by inhalatio n o r subcutaneo usly , it producessymptom s o f asphyxia , dim inution of temperature, partial flaccidity of

musc les, and lessens sensibility witho ut c omplete ly destroying it . In

man it caused a tendency to sleep , and fo rm ic ac id appeared in the

urine.

Bichlo ride Of methylene has been rec ommended a s an anaestheticGaine§ and Spencer Wells

, ” but its administration i s not withdanger, death having o ccurredfil during anaesthes ia pro duced by it .M ethylamine .

—Fargier-Lagrange** finds that trimethylam ine,do ses o f about 9 gra ins daily, lessen s pa in in rheumatism . Itthe resp iration and pulse, and reduces the temperature.

N itrite of amyl .—H. C . Wo o d

,finds that nitrite of

greatly lessens, but do es no t destro y, the irritability o f nervemuscles . The power o f the central m o to r ganglia isdim inished, but sensibility is only slightly lessened. He

Brunton that the dim inution in the blo o d-pressure which nitrateJourn . de 111, p . 3 28 S chm idt ’s J c l iii, p . 14 1 .

1' ‘Comp . Rend ,

’1872 , p . 1 2 0 2 .

I Ib id. , 187 1, lxxu , p . 74 2 .

‘Med. Tim es and 187 1, p . 2 3 2 .

ll‘Lancet, ’ 187 1 , i, p . 59 1 .

if‘Brit. Med. 187 1 , p . 45 7 .

3” ‘Virchow and Hirsch ’s 187 1, p . 34 1 .

“H‘Amer. Journ . Med . July, 187 1 , p . 39, and Octo ber, p . 359.

468 REPORT ON MATERIA MEDICA, ETC .

and in neuralgias,crural and brachial, succeeds when other remedies

have failed. He also recommends it in do ses o f 2 0—30 grain s fo rfrontal headache resulting from m ental fatigue, and in cases Of gangrene o f the lungs, pyaem ia, and diphtheria .

Aconitine.—H . Duquesnel has recently obtained this alkalo id in a

c rystalline c ondition from Aconitum nap el lus , by a m odification o f

Stas’s m ethod, and he states that hitherto the term aconitine has beenapplied to several substances differing in therapeutical value with thesource from which they are derived. He regards the alkalo id

,to which

he assign s the formula Cz7H40NOm, as a gluco side, and c onsiders that

this view explains the spontaneous deterioration o f various preparationso f it on keeping . T he chem ical properties o f acon itine are full y described, and pho spho ric ac id

,tannin, p otassio -mercuric iodide, and

iodine in po tassium io dide, are stated to b e the m o st sensitive reagentsfo r it .The same Observer

,in conjunction with M . Gréhantd

' describes thephysio logical action o f the crystallised aconitine prepared by him .

From experiments on frogs, they c onc lude that small do ses of aconitineare analogous in physio logical results to curarine, destroying the

m o to r ower o f nerves,but with large do ses the heart’ s action was

arrested)

,and the nerves did no t lo se their m o tric ity, because, through

cessation o f the c irculation,the did not c ome in conta ct with the

p o ison . In mammalia,the eflects o f the po ison are m ore rapidly deve

loped, and are mo re difficult to analyse.

0piwm .—O . Hesse i ha s described some new alkalo ids from opium

-laudanine,c odamine, meconidine, and lanthop ine . These c o llec

tively, when impure, fo rm the po rphyro xine described by Merck . The

physio logical and therapeutical properties o f these new bases have notyet been ascertained.

Rabuteau § has investigated the action o f the alkalo ids of Opium,

and c lassified them ac co rdingly . The alkalo id having the m o stpowerful action i s placed first

,and that having the weakest is placed

last . They stand in this o rder as s oporific s—m o rphine,narceine

,and

c odeine . The o ther princ iples have no sopo rific action . As p o isons

tine, as he suppo sesby o smo sis from th

mo tie, and next to it c omes narceine. The O

to arrest diarrhoea . Opianine i s present itity . Its action is like that o f m o rphine.

have no ac tion whatever.

Op ium and ekloroform .

—Labbe and and Guyon IIhave confirmed thestatement o f Claude Bernard and Nussbaum

,that when mo rphine is

3“ Comp . lxxiii, p . 207.

1” Ib id ., p . 2 09.

1‘Ann . Chem . Supp ., Bd. viii, p . 261 .

Journ. de l’Auat. et de 1872 , p . 30 2 .

H Journ . de Pharm . et de 1872 , p . 398.

MONOBROMIDE o r CAMPHOR. 469

given along with chl oro fo rm much smaller do ses of chlorofo rm are re

quired to pro duce c omplete anaesthesia than when it is given alone, andthe risk o f death o ccurring is thus diminished. The anaesthesia lasts along time, and may be pro longed still farther by small do ses o f chloro

Rabuteau finds nearly all the principles o f Op ium ,with the excep .

tion of narco tine,aid the action o f chlo ro fo rm . Morphine is the mo st

p owerful in this respect, but narceine is nearly equal to it . Codeineand papaverine have only a feeble action .

Ap omorp ki/ne.—The action of this substance has been investigated by

Vincent Silbertsi' The m inimum do se required to produce vom iting,when injected subcutaneously, is about one tenth o f a grain . A grainand a half given by the stomach pro duced only nausea in one case

, butmuch smaller do ses may sometimes pro duce vom iting.

Quehl i finds that the do se required for sub cutaneous injection isr- r2 o th to 1 -3 o th o f a grain ; by the m outh

,1% to 23; grains ; and by

the rectum ,2 % to 5—5 grains . NO to lerance is produced by its long

continued use, n or do es it injure health . E xcessive do ses, 3 grains o rmore, do not produce vomiting at al l

,but cause staggering, weakness,

and manage mo vements . Vomiting is also prevented by division of thevagi nerves .Blaser § recommends simple syrup as

fi

the best so lvent for apomorhine .pMus carine.

—~ This alkalo id has its chemical characteristic detailed byRuckert. ” It is recommended by Deneffe !Iin delirium tremens . He

gives it in do ses o f 45 to 60 grains daily, in the form o f pill .( h awker—Dr . O . has investigated the action o f campho r

on the heart,and o btained results o f much therapeutical interest . The

results were o bta ined by experimenting on frogs . He finds that camphor renders the cardiac c ontraction s m ore energetic , the pauses between the c ontractions o f longer duration, and that the heart bestowsupon the c irculation greater rap idity .

M onobromide of camphor—Dr. Wm . A . Hammond ‘H’ has tested the

alleged efficacy o f this medicament, and his experience o f its use, thoughthus far lim ited

,is em inently satisfacto ry . The preparation used was

in beautiful crystals free from the slightest yell ow tinge, hence it contained no free brom ine. E mployed in two cases o f infantile c onvul

sions due to the irritation o f teething, the bromide prevented thefurther o ccurrence o f paroxysm s which , previously to its administration

,had been very frequent . In each case a grain was given every

hour,rubbed up with a l ittle muc ilage . Three do ses were suffic ient in

one, and two in the o ther case. In a very Obstinate case o f hysteria ,in the fo rm o f paroxysm s o f weeping and laughing, alternating with

if Journ . de l’Anat. et de 100. c it.

1'‘Untersuch . u . d. W irk . d. Apormorph . Diss. Derpat , ’ 1871 .

I ‘Diss . Halle,’ 1872 .

Arch . (1. xii i, p . 2 72 .

II‘New Rep . xxi, p . 193 .

fil‘Presse Med. Belge, ’ l, p . 405 .

‘Arch . d. xi, p . 334 .

"M ‘New Y ork Med. Joma ,

’xv, p. 52 2 .

470 REPORT ON MATERIA MEDICA, ETC .

epileptifo rm and'

choreiform convulsions, where the acts usually lastedfrom five to eleven days

,uninfluenced by medication o r m o ral suas ion

,

the influence o f the drugwas distinc tly perceived after two do ses (fourgrains every hour) were taken ,

but ten were necessary to entirelybreak o ff the attack . Dr. Hammond also speaks highly o f the brom idein headache from mental excitement . In wakefulness it is inferio r too ther bromides, as , e.g . brom ide o f calcium .

Digita lis .—Dr . Rudo lph Bo ehm

,

* o f Wurzburg, has investigated thephysio logical ac tions o f digitalis and digitalin . He finds that digitalinincreases the irritability o f the inhibito ry nerve-centres situated in theheart, and exerc ises a spec ific action on the muscular fibres of theheart

,first o f all increasing their c ontractility, next rendering their

c ontractions irregular, and finally conferring upon them a pecul iarrigidity . The essay is a long and valuable one .

Dr . A . Weil “t contributes a paper on the physio logical actions of thisdrug. His mem o ir is very instruc tive , but as the objec t of the experiments, made upon fro gs

,was to demonstrate the m echanism Of the

reflex inhibito ry centres (reflexhemmungs mechan ismen) , we do not

think it necessary to do mo re than make a sho rt reference to them .

He finds That small do ses o f digitalin (1 -60th of a grain ) dim in ish very c onsiderably in decapitated reflex frogs (a term applied toto fro gs in which, on the previous day, the cerebral hem ispheres hadbeen separated by cutting through the bones) the frequency o f the

heart’ s action ,the heart ’s beats being sto pped so oner in the decapitated

animals than in tho se which had not been s o treated. The same o c

curred with do ses o f 1 -3 o th o f a grain . (2 ) Small as well as largedo ses act as excitants o f the inhibitory centres . (3) Large and smalldo ses induce a period at which division o f the medulla o blongata no

longer restores the reflex irritability, at which perio d also the irritationo f the inhibitory centres has given place to paralysis of the co rd. Pre

vious to this , the action o f the digitalis is limited to the brain, so far asreflex excitation is concerned.

G ourvat i finds that a moderate quantity o f digitalin paramo tor nerves o f vo luntary musc les in frogs, and that a largedestroys the irritability o f the musc les themselves . It seem sa stimulant to invo luntary musc les . It causes c ontraction of

rio les and raises the b lo oslower, stronger, and mo re

muc o

Ackermann § has investigated the action o f digitalin—1st

heart ; 2nd,on the arteries ; and 3rd, on the temperature . He fin

‘Arch . f. v, p . 1 53 .

1‘ ‘Arch . f . 187 1 , p . 2 5 2 .

I Gaz . 1871 , No . 2 6, et s eq . ; Gaz . des cxxxu, p . 5 26.

‘Berl . Klin. 1872 , 2 7 ;‘Deut. Arch . f. Klin . xi, 1 2 5 .

REPORT ON PUBLIC HEALTH .

THOMAS STEVENSON , M .D . LOND .,

LECTURER ON CHEMISTRY AT aux’s HOSPITAL ; MEDICAL OFFICER OF HEALTH

POR ST . PANCRAS .

Cho lera .

CHOLE RA is the disease which has attracted the largest amount o fattention from san itarians during the last two years, and the li teratureof the subject has been very abundant .The recent difiitsion of c lzo lem in E urop a

—A repo rt o f remarkableinterest on the recent diflusion o f cho lera in E uro e* has been sent byMr. J . Netten Radc liffe to Mr. Simon ,

who has orwarded the reportto the president of the Lo cal G o vernment Bo ard, with a rec om

mendation that it be brought under the oflicial no tice Of fo reign go vernments . The report c omm ences with an acc ount o f the first appearanceand subsequent progress o f the epidem ic which , beginning in SouthRussia at Kiev, in the autumn o f 1869 , Spread during the m onths o fN o vember and December into several o f the districts in South, Centra l,and West Russia . In January o f the fo llowing year cho lera appearedin Mo scow, and in February cases were reported from No vgo rod.

During the summ er and autumn the disease Spread actively, so that in1870 cho lera revailed with hardly a break if indeed with any breakthroughout t e tract Of c ountry lying between Mo scow and the northco asts o f the Black Sea and the Sea Of Az o v. T o the north and westof this tract it had appeared at St. Petersburg ; and to the south andeast it appeared along the no rth-east coast o f the Black Sea, from the

Straits Of Kertch to Po ti, through the valley Of the Rion acro ss Transcaucasia to the Persian frontier Of the empire. In 187 1 cho lera wasgenerally diffused throughout Russian E urope . It ead also intoS iberia, appeared in the autumn at Astrachan, prevailalong the c ourse o f the Kouban,

and in Transcaucasiaat Baku on the west coast o f the Caspian,

and at E rivan .

who le progress of this remarkable diffusion of cho lera,th

not spread into E urope beyond the lim its o f the Bus

except at four p o ints . In July it passed the Po lish frontiPrussia

,and on the 2 4th of the m onth attacked KOni

August it extended to Memel, Dantzic , E lbing, Stettin , Sat Parliamentary Paper.’

CHOLERA . 473

and the adjacent districts ; scattered cases were also recorded in Berlin,

and outbreaks o f the disease o ccurred in Hamburg and Altona .

On the 3rd of September it appeared at Herno sand in Sweden,and

at the same date at Constantinop le . In O cto ber,cho lera was rep orted

to be present on the Danube at Sulina and Galatz, and in No vember atT ultcha . At the commencement o f August an outbreak o c curred inAsia Mino r at Brusa in Anato lia

, a c omm erc ial town of considerablesize, with a port at Mundania on the Sea of Marmora . At this timecho lera was prevalent at the ports of Kherson, Nico laiev, Taganrog,and Ro stov on the Don to the north ; and at Bagdad, and severalpo ints in Turkish Kurdistan,

in the vic inity of the Pers ian fro ntier,

and in the province o f Azerb ijan in Persia to the east and south-ea st .Previous to the outbreak , cho lera had spread largely along the c oursesof the E uphrates and Tigris within the pashalik of Bagdad, and hadextended into E astern and N o rthern Arabia . From Brusa

, cho leraSpread to the surrounding districts and

,subsequently to the appear

an ce of the disease at Constantinop le, cases o ccurred in the lazaret atSalonica and in the vic inity o f that town

,and in the lazaret at Varna

in E uropean Turkey, in the island Of Cerigo , at St. Jean d’Acre on theeast co ast o f Asia Minor, and at Sam soun and Trebizonde on the northcoast, and at Amasia in the interior o f Anato lia . The cases at Salon icaand Varna o ccurred among passengers who had recently arrived thereby o rdinary steam transit from Constantinop le . The first case at St.

Jean d’Acre was landed from a Russian steam-vessel c oming also fromConstantino ple . On the 10th of O ctober an ill-furnished emigrantsteam ship sailed from Stettin for New Y o rk

,touching at Copenhagen

and Christiansund. About a week after this vessel had left Christiansund cho lera appeared among the passengers , 6 10 in number . She putinto Halifax

,N o va Sco tia

,o n the oth o f No vember, and introduced

cho lera into that c ity and into the village o f Chezetco ok,twenty-five

miles north Of Halifax . In the co urse Of September two cases of

cho lera were imported by steam ships from Hamburg to E ngland, bo thinto the po rt of Hartlep o o l . One of these cases

,which ended fatally

,

v

ir

l

as imported on the 7th o f the m onth ; the o ther, which recovered, ont e 18th .

While these events were taking place in E urope, cho lera was alsoSpreading rapidly from the head o f the Persian Gulf along the c ourseso f the Shat-el -Arab , the E uphrates , and the Tigris, within the pashalikof Bagdad, in which pro vince the disease had appeared at Meshed Ali

,

in December o f the previous year E arly in the summer of

187 1 a Turkish expeditionary fo rce became affected with cho lera at

Bassora,as it was about to embark for Koweyt, and carried the disease

into E astern Arabia . About the m iddle o f June cho lo ra broke out at

B ayel in the Djebel Shomar, No rthern Arabia , intro duced there, it isstated

,by an infected caravan c om ing from Meshed Hussein . From

B ayel the disease passed, two months later, to Khaiber, three days’journey from Medina , and in September it broke out in the latter town ,

at a time when numerous p ilgrim s were there . In November cases arestated to have o ccurred at Mecca , and in December a severe outbreakoccurred on the east coast of the Red Sea

,at Gonfudah, south of

474 REPORT ON PUBLIC HEALTH.

Jedda . The disease appeared at Go nfudah among troops recentlyarrived from Constantinople, and it prevailed chiefly among the garris on . Cases subsequently o ccurred at Jedda and Y embo towards thec lo se of the year .

The source o f the remarkable diffusion Of cho lera in E uro pe during1869 , 1870 , and 187 1 , is a question o f c onsiderab lej nterest , and Of imp ortant practical bearing . Dr . Pelikan ,

the Directo r Of the ImperialMedical Department o f Russia, is o f opinion that the diflusion was no ta new epidemic , but that it was a recrudescence o f the epidem ic Of 1865 ,an Op inion which is shared by Dr. Fauvelfi“ Mr . Radcliffe is unable toa ccept this theory as suflicient to explain all the phenomena o f the

diffusion . He cal ls attention to the fac t that this diffusion was preceded by the m o st co nsiderable develo pment o f cho lera in No rth Persia,articularly in the Caspian pro vinces o f the kingdom ,

that had o ccurredfo r several years . Previous outbreaks o f cho lera in N o rth Persia o f

like extent had been invariably fo llowed o r ac c ompanied by the appearance o f the disease in Russia . The history Of cho lera in Persia since1865 is Of much interest in relation to the subjec t under c on sideration .

The persistence and recurring activity o f cho lera in Persia from 1866

to 187 1 , although paralleled by previous perio ds Of long-continued prevalence o f the disease—for example, from 1 85 1 to 186 1—have led someObservers on the spo t to question whether the malady is not bec ominnaturalised in Persia. From 1865 to 1 868 the genera l movement 0cho lera in Persia had been from west to east .W ith the return o f a band Of pilgrims from Meshed in July , 1868,when cho lera raged with great vio lence, a reverse m ovement began ,

and with it indications Of greater diffusiveness o f the malady . Thisdiffusio n

,in the c ourse o f 1869, spread o ver the greater portion o f

No rthern, Western , and Central Persia, and throughout Irak-Arabi, inthe ashalik o f Bagdad.

r. Radc liffe is o f o pinio n that the prevalence o f cho lera in Persiacanno t b e rightly studied without , at the same time, a study Of theprevalence o f the disease in India . N ow

,in 1867 , cho lera, which had

broken out with much fierceness among the multitude Of ilgrims

assembled at Hurdwar for the great annual religious Hindu fair heldthere

,fo llowed in the track o f the p ilgrims returning northwards

into Afghanistan , and towards the c lo se o f the year it was prevalentat Cabul . In 1869 it again became epidemic o ver the who le o f the

Bombay Presidenc y and No rthern India, and spread anew into Afghanistan . The great trade ro ute between Persia and India throughAfghanistan ,

by way o fHerat to Meshed, has been the track chiefly fo llowed ih previous Invasions o fPersia by cho lera m igrating from NorthernIndia and Meshed, from its large commerce

,as the prin

trade between the two c ountries and Afghan istan, andbeing the fo cus Of a great pilgrimage from all partsalways played a very important part in the diffusmn of cho lethe disease has been intro duced there .

Mr . Radc liffe thinks that the outbreak o f cho lera at Meshedand the subsequent diffusion Of the disease from that c ity was In

Bulletin de l ’Académie de Médec ine,’ xxxvi,


po rt o f Souakin ,by way o f the Red Sea . The Taka country is a dead

flat converted in the ra iny season into an imprac ticable slough, but atpresent under pro cess Of rec lamation by the Khedive for the purpo seso f c o tton cultivation . It was am ong the labourers engaged in thesewo rks that the o utbreak o f cho lera o ccurred, and, according to rep orts ,brought among them by camel drivers from Souakin. Cho lera prevailedamong the wo rkers from the c lo se o f June to the c lo se Of August

,when

it seemingly ceased but in O ctober the disease reappeared, and spreadamong the native tribes o f the Taka c ountry, This sec ond outbreakwas of great severity, and it probably did no t come to an end till thebeginning o f December. From the Taka c ountry cho lera, in August,extended to Berber. There it broke out with vio lence, and prevaileduntil the beginning o f O c tober , causing a great m ortality . On the 3rd

and 4th Of September the deaths from cho lera were reported to havebeen 2 00 . In September the disease attacked the tribes o ccupying thec ountry west o f Berber, and it was carried by them southwards towardsKordofan, andnorthwards into D ongo la . Up the N ile, cho lera appears

to have passed from Berber into the Halfaya distric t, where the diseasewas probably present in N o vember, and down the N ile, scattered ca seswere reported as low as Koro sko .

The probable source Of this outbreak form s one o f the mo st interesting episo des in the histo r

fio f the late westward diflusion o f cho lera .

As already related in Mr. adcliffe’

s report , cho lera spreading from thehead o f the Persian Gulf was carried to Mec ca and Gonfudah at the

c lo se o f 187 1 . From G onfudah the disease was carried by the tro op sto Ho deida in the fo llowing February . In Mec ca the malady was supp o sed to have disappeared at the c lo se o f January, I 872 . From the 19th

to the 2 3rd o f February a great religious festival was held in Mec ca,at

which upwards o f pilgrims were c ongregated in and around the

c ity during tho se days . On the 2 7th o f February cho lera reappearedin Mecca

,the earliest cases being Observed among the Takruri pilgrims ;

that is to say, negro pilgrims from Nubia and Central Africa . Thesewere in a mo st destitute condition . The number o fwest co ast o f the Red Sea who attended the festivalexceeded 2 500 . Befo re the reappearance Of cho lera to f the pilgrim s had left Mecca . Two great caravans ,the E gyptian had started about the 2 5th Of Febru

these caravans got c lear o f the c ity when cho lera appeared amongc ausing great mortality . Cho lera was intro duced by them into MIn the track of the return ing pilgrims, who diverged from Medinasea co ast, cho lera rea peared at Gambo in March

,and did no t

until April . Jedda, owever, escaped. In April,also , cho lera is re.

po rted to have ceased in Ho deida .

The outbreak Of cho lera in the Taka country fo llowed upon theOf events here related, and the disease is surm ised to have been 0

to Taka from Hodeida by way o f Souakin . The particular stepstransmission are no t known . The time o f the outbreak fo llowed

among these pilgrims when, at the clo se o f February, it reappeared in

CHOLERA. 477

that c ity . T o what extent E urope owes its s afety from last year’s outbreak Of cho lera in the Hedjaz to the energetic m easures adopted bythe E gyptian G o vernment, to prevent the intro duction o f infectedp ilgrim s into E gypt, and their passage through the Suez Canal to po rtsin the Mediterranean, it would be difficult to say . But the preventivemeasures taken were well c onc eived and well carried out, and theyOffered the greatest chance o f pro tection to E urope from the importationo f the pestilence .

The comparatively light diffusion of cho lera in Upper Nubia appearsto have been to some extent due to the m il itary c o rdons established bythe E gytian G o vernment .Cho lera in the B ritish is lands . Considerable apprehension was

entertained in this c ountry during the c ourse Of bo th 1871 and

1872 Of an invasion o f our shores by Asiatic cho lera ; and,indeed,

E ngland was on m ore than one o c casion invaded by the disease,though , thanks to the precautions taken ,

no extension o f the diseaseo ccurred.

Having fo r nearly two years been in Russ ia,f and since August , 1870 ,more o r les s in St. Petersburg, cho lera in the spring and early summer

o f 187 1 spread som ewhat c onsiderably in the Baltic provinces o f

Russia, and at the end o f July began to to uch the co ntiguous parts o fGermany, when, so on after

,Ko nigsberg sufferedmo st severely . With

cho lera actually epidem ic at St. Petersburg, Cronstadt and Riga , andlikely so on to becom e ep idem ic at parts still nearer to E ngland, it wasevident that ship s from the Baltic m ight in certain cases b e a source of

danger to this c ountry . Since quarantine in this c o untry was no t to

be thought o f, the step s taken by the British G o vernm ent were mainlythese z—Lo cal authorities (and espec ially p ort authorities) were warnedof the danger in question, and were advised Of the precautions whichin the present state Of our kn owledge are regarded as o f m o st valueagainst the infection o f the disease and every legally po ssible fac ilitywas given for the lo cal exerc ise o f such precautions . Facilities were

given for the exam ination o f ships arriving from the Baltic ; and a

central inspector visited our p orts to c onfer with the lo cal authoritiesas to the provis ion Of ho spital acc omm odation

,&c . Never befo re was

the extension Of infection from the first imported cases s o successfullyand c omp letely met .

Ground water.—Pettenkofert returns to the subject of the influ

ence o f ground water on cho lera and typho id fever in a paper on

typho id, cho lera, and ground water in Ziirich . Sp ite o f the opp o sitionhis views have met with , and the facts urged in refutation o f the

validity o f his c onc lusions, Pettenkofer still adheres to his now wellknown views on this subjec t.Dif fusion of cho lera in India—Pettenko fer ,? in a small work has

entered into an exam ination Of the recent reports on cho lera in India byMacpherson,

Murray,Macnamara,Cunn ingham ,

Lewis,Bryden

,&c .

, andit First Report o f the Lo cal Government Board, ” p . lv.

1” Zeitschrift f . Bio logie,’ vii, p . 86.

I‘Verbreitungsart der Cho lera in Indien .

’ Braunschweig, 187 1 . The Diffusion Of

Cho lera in India .

’ Translation in ‘Indian Annals o f Med. Sc ience, ’ NO . xxix,pp . 176 —300 .


states his own conclusions in the fo llowing theses . I) In India there are

one or m ore regions in which cho lera has had its endem ic site since them o st anc ient t imes with a prevalence fluctuating ac c ording to the seasono f the year . The cause o f the disease and its endemic ity canno t b e lo okedfo r in the people living there, but is to b e lo oked for in a yet nu

known relation between the spec ific disease-

germ and the so il and

climate. (2 ) Cho lera in India has at all times periodica lly diffuseditself in the form Of epidem ic s from the endem ic districts o ver o thertracts o f land. As the means o f diffusion some people in India assume

the currents of air, Spec ially the m onso ons (the mia sm atists , Bryden) ,o thers hum an interc ourse, spec ially through the excreta Of cho lerapatients (c ontagionists , Macnamara) , while o thers allow the diffus ionin bo th these ways . T he propo sition go es on to state that neither of

these view s suffic iently exp lains the facts, but that along with humaninterco urse there must b e c erta in lo cal and perio dical c onditio ns , andthat diffus ion by currents o f air alone is c ertainly no t in harm onywith what has been Observed in India . 3) That which determines thelo ca l thriving of the cho lera germ ,

which may be called a,do es not

pro ceed from the human o rganism , but from the lo calities due to yetunascerta ined pro ces ses in the so il . This princ iple applies n o t o nly tothe endem ic c irc le but to al l places in which epidem ic s o f cho lera are

develop ed. The substratum furnished by the lo cality o r so il,on which

the lo c al and perio dica l dispo sition fo r cho lera epidemic s is dependent, m ay b e called y . The cho lera germ :r is able to travel withhuman beings

,the true substratum g/ is asso c iated with the lo cality .

(4) That part o f the ch o lera pro cess which go es on in the so il, and on

which the periodic rhythma Of cho lera preva lence is essentially dependent

,bo th in the endem ic and epidem ic regions , requires, in additio n to

o ther c onditions , a certain medium amount o f so il mo isture . Bo th greatpersistent dryness (as in deserts) and excessive c oin the Ganges Delta towards the end o f the rains)unfavo rable to cho lera . On

and ho t districts with s cantycho lera usually prevails inm onso on cho lera) , whilst in tdant rain-fall prevailing in

conditions , stand as regards their ra in-fall in the m ean bet

and Calcutta, Show also,with to lerable regularity, spring

cho lera in ‘

one and the same year.

Whenever,as the result o faltered conditions of ra in and

the mo isture o r so il-water conditions in a place deviate fromexisting rule, the periodical rhythma and prevalence o f ch

place are likewise altered, so that such a p lace, fo r ex

Instead o f revalent spring cho lera, can also exceptionallcho lera an vice vered.

One and the same amount Of rain acts on diflerentlyand on so ils which differ in their dryness o rmo isture in e


I st. That with the present extremely imperfect data it is quite premature to dec ide exc lusively in favour o f any one theory regarding thelo calisation Of cho lera .

2 nd . That several o f the existing theories may really invo lve partialtruths, and that they only bec ome inc ompatible with one ano ther wheninsisted on as abso lute and entire explanations .3rd. That although in the repo rt much stress has been laid on the

so il theory it is not on ac count Of any assumptio n o f its essentialsuperiority to the o thers

, but because it appears to b e little understo o din this co untry (India) , and to b e regarded with a c onsiderable amountOf prejudice in c onsequence. It has seemed to Dr. Cunn ingham ,

therefo re, very desirable that the existenc e o f any facts in its favour shouldbe distinc tly put fo rward, and the m ore s o that there seem s to beeno ugh o f these to fo rbid the who lesale rejection o f the theo ry, and towarrant the c ontinuance Of careful Observations which may teach intime the laws Of the asso ciation o f ground m o isture with the propagation o f cho lera .

Dr. Zehnder’

s report on the cho lera epidemic in Zurich in 1867* c on

tains much valuable info rm ation on the origin and diffusion o f thisdisease . He regards water-c lo sets contam inated with cho lera de

jection s as the m o st c ommon c ause o f contagion, from the germ sgetting into the air and thus gaining access to the alim entary c anal .He did no t Observe that drinking water p layed any impo rtant part in thediffus ion o f the disease. Meteoro logical c onditions did not seem to

exert any special influence on the spread o f the ep idem ic . T he yearThe nature of the so il

,as well its c onfiguratio n, its

break the surface was to lerably dry at the end

when the disease was spreading) the rain had can

m o isture Of the so il, while in September the mo isep idem ic gained in strength . From the m iddle toat which time the epidem ic ceased, the mo isturetill it reached the same c ondition o f dryness as at th

o utbreak o c curred. Hence the disease began with athe so il

, gained energy as the m o isture increased, an

less active as the dryness returned. Accumulations Ofhouses exerc ised little or no influence on

but the ac cumulatio

exerc ised a mo st prejo f the c ontagion .

methods taken and

o nce infected after dis infection o f the same, and the use

which are to b e carefully disinfected and emptied out o f

(2 ) the fo rmation o f privies for the c onvenience o f tho shouses or neighbourho od cases o f cho lera have o ccurred

,

if Virchow and Hirsch ’

s J 187 1 , i i, p . 2 14.

CHOLERA. 481

mode of life renders it impo ssible in them to avo id the infecteds o ts .pE richsen* investigates Pettenko fer’ s subso il water theory in re

ference to diffusion Of cho lera in St. Petersburg, and c omes to the

c onclusion that in reference to this town it is insuffic ient to ac c ountfor the facts observed in regard to the outbreak and spread o f the

disease .

Pfeifferd’

who is a firm believer in Pettenko fer’s subso il water

theo ry, writes on the influence o f temperature o f the so il o n the o riginand Spread of cho lera . He believes that the temperature o f the so il

,in

addition to the state o f humidity and state as regards putrefactivechanges , exerc ises a very important influence on the causatio n o f

cho lera and its allies . As to arctic regions there are no data on wh ichto build, and in the trop ic s the uniform temperature o f the s o il canhave little influence . In reference to temperate c limates, however,Pfeiffer finds that the acme o f an epidemic of cho lera c o inc ides with theseason o f the greatest superfic ial temperature o f the so il ; that thecho lera dim inishes with the rap id decrease Of the temperature , and thatwhen the so il has a temperature under 4 1°—45° Fahr .

,the disease eu

tirely disappears . The causes o f the variation in so il-temperature are of

course numero us , such as the temperature o f the air,the c onductivity o f

the so il, the humidity, &c . The value Of each o f these factors theauthor has studied in the ep idem ic at Weimar in 1870 . The fac ts areas yet to o few to allow of very general c onc lusions being drawn, but

he thinks that mo re attention should be paid to a subjec t whichis likely to throw much light on the etio logy o f cho lera and o therdiseases .Causes of cho lera—Honerti believes that cho lera depends on po ison

ing with amm onia which is set free a long with so -called marsh gasduring the dec ompo sition o f nitro genous substances . Cho lera and

malarious fever have, therefo re, a sim ilar origin . Cho lera germs are an

absurdity, and the disease is truly auto chthonous .Barth § also suppo ses that cho lera i s due to the action Of a spec ificpo ison generated in the earth, and that this po ison paralyses thenervous system . Commun ication from one person to ano ther is an un

warrantable suppo sition . The po ison is evo lved into the air o r bec omesdisso lved in the water in the ground, and s o gains access to the system .

Cho lera coutagiou .—P0p o ff

'

IIhas made severa l experiments in regard tothe infectingp ower o f cho lera excreta , and has compared the effects produced by putrid infection . His experiments were made o n dogs . Asmaterial for putrid infection he used infusions o f putridm eat and ro ttenyeast , and fo r cho lera he employed the vom itedmatters , faeces , andurine,in a fresh condition . Thematerials were introduced partly into the cir

culation direct, partly into the alimentary canal . The differences between the symptoms and po st-m ortem appearances in the two cases

‘St. Petersburg Med. Zeitschr., 1, p . 3 2 5 11, pp . 437, 537.‘

f Zeitschr. f . Bio logie, ’ vii, p . 2 63 .

It Virch ow and Hirsch ’s J 1871 , 11, p . 2 2 2 .

Ib id., p . 2 2 2 .

‘Berlin Klin. 1872 , p . 393.


are accurately and minutely detailed . Of the latter the mo st characteristic differences are observable in the alimentary canal . In putridinfection the signs are tho se o f simple gastro -enteritis haemo rrhagica(Bergmann) without spec ial affection Of the lym

phatic glandular

apparatus, while in cho lera these are affected in a mar ed degree.

He draws the fo llowing c onc lusions( 1) Cho lera excreta are undoubtedly contagious, as well the vom ited

matters, as the dejecta and the urine. 2 ) Cho lera excreta are

specially contagious in the fresh condition . (3) Decompo sed excretacause a m odification o f the cho leraic symptom s and induce a c on

dition resembling putrid infection . (4) The infection can be causedby direct intro duction o f the po ison into the blo o d, without havingpassed the alimentary canal . 5) The action o f the cho lera p o ison do esno t begin at once, but general ly after one to three days o r longer.

Organisms in cho lera—In a paper on the micrography o f cho lera ,*Nedsvetzki states that from his m icro scopical investigations o f

cho lera blo od and cho lera excreta he has been able to c onfirm the

statements o f Klob, Thome, and o thers, and he likewise claims to havemade some fresh dis coveries . In the dejecta, vom it, and urine of

cho lera patients he finds in all, (I ) an upper la er consisting o f Oil

globules o f various sizes ; (2 ) a great number 0 epithelial cells m o re

o r less altered such as o ccur in diphtheritic products ; (3) the cells areall filled, as well as the fluid in which they o ccur, with myriads o factively m o ving o rganisms . These o rganism s are o f various fo rms ;granules single and united in a ro sette form

,rod-shaped o rganisms,

a granular mass compo sed Of m inute cellules . These he call s cho lerabacteridia ; (4) red and white blo o d-corpuscles fil led with the sameo rgan isms ; 5 ) mucus ; (6) o cca sional spores resembling tho se o f

aspergill us and penicillium .

In the blo od from the skin, thejveins , and the heart, he found a greatero r less number Of fat-globules . In all cases he found the red blo o dc orpusc les m o re darkly co loured and less trans arent than usual . The

darkest blo o d was found in the parenchyma o the lungs . The whiteblo o d-co rpuscles were no t in creased in number. The chief differenceappeared to b e that in many cases they had passed into a granularmass and had lo st their individual c ontours . The granul es after a timebegan to mo ve like the previously described o rgani sm s .The blo od in the capillaries , as studied in fine sections Of the skin

hardened in chromic ac id, exhibitedgranular masses compo sed of o rgan ismHe also states that the expired air o f

ridia . These he regards as the carriers Of cho lera infection .

paper (‘Mo scaner Med. Zeitung ’

) in which his researches are plished at length, the autho r enters into o ther investigations intonature o f cho lera parasites , but which are no t here deta iled .

Fo reign jo urnals j' fo r the year 1871 are rich in c ontributions‘Centralblatt. f. (1. Med . 187 2 , p . 2 3 2 .

f Vida Virchow and Hirsch ’s ‘J 1872 , i i, p . 2 26.

484 RE PORT ON PUBLIC HEALTH.

year and fo llow increasing hum idity ; whence it remains undeterminedwhether, in contradic tion to the first prop o sition, hum idity favoursthe development o f typho id, o r whether it is a late effec t o f the

previous drynes s, o r whether it i s entirely due to temperature. (4)The mo vem ents o f the disease are the sam e in all parts o f the c ity,whether h igh o r low,

o r near o r at a distance from the Rhine . 5)The ep idemic do es no t selec t one part o f the c ity more than ano ther.

Mr. De Renzy* has given a remarkable instan ce o f the extinction o f

enteric fever in a prison by the simp le m etho d o f changing the supplyOf drinking water. Fo r m any years som e o f the ablest o f o ur

metrop o litan phys ic ians failed to detect the true cause o f the un

healthiness o fMillbank prison, and as signed various causes fo r it whichlater experience has pro ved to b e unconnected with it . E nteric feverwas rife from time to time in the gao l . In the year 1854, however,the water supply was changed with the best po ssible results . Pre

viously , the water used for drinking purp o ses in the prison was

pumped direct from the Thames, but was Of c ourse filtered befo reuse . The water used fo r domestic purpo ses is n ow supplied by the

artesian well in Trafalgar Square. The change was carried into effec tin the m idst o f the cho lera epidem ic which was then s o severelyvisiting Londo n, and the prison was suffering from cho lera at the

time . Six days after the change the disease suddenly ceased,and a

m arked impro vement to ok place in the health o f the pri so ners . Fromthe date o f the introduction o f the new water supply up to April 1872 ,a period o f nearly 19 years , there have been onl y three death s fromenteric fever, viz . one in I S55 , one in 1860

,and one 1 865 .

Mr. De Renzy thinks that the sanitary h isto ry o f Millbank—whichhe gives in detail—appears to warrant the fo llowing c onc lus ions

I . That the extin ction o f enteric fever,and o ther diseases o f the

same c lass, is quite within the range

extinc tion o f o ne c lass o f zym o tic dis

against every kind Of zymo tic disease .

is the great Obstacle to ,the extension

pO ulation . 3 . That since some o f th

fai ed fo r many years to detec t the trueMillbank Prison

,and assigned causes

o f temperature, mo ral depression, and o ther intangiblewhich would b e entirely remo ved by the general disusewater. 4 . That as it required long years o f Observation tthe noxious influence Of Thames water in Millbank

,even

filtered, under conditions very favo rable fo r detection, we

Lancet, ’ 1872 , i, pp . 787, 820.

ENTERIC FEVER. 485

cautious in accepting the Opinion , based on the resul ts o f chemicalanalysis , that the use Of that water by the population o f London is freefrom danger .

The Second Annual Repo rt o f the State Board o fHeal th OfMassanumber o f queries and the replies to them ,

fromowns in the State, in reference to the causes o f

stions and answers( 1) Have you o bserved a difference in the prevalence o f this disease

between houses supplied with water from wells ab out the premises andhouses supplied with water c onveyed from springs o r from p onds Ofunquestionable purity P—Replies z “ Y es

,

”2 3

“no difference has been

remarked, ” 7 1 who le supp ly Of towns from wells, 18 ; indefinite, 5 1 .

(2 ) Can you info rm us whether, at times,when typho id prevailed,

the water o f the wells was rising or falling, and whether it was higheror lower than the average for the year ? (To this question is appendeda no te recommending Observation o f the height o f the subso il water infuture, if attention had not previously been directed to it.) -RepliesRising after being very low,

I I falling, 1 6 ; very low,2 8 ;

“ have no tobserved, ” 1 00 .

5 (3) Have you o bserved any connection between typho id fever andfoul so il

,whether from privies, p igsties, manure heaps , or similar co llee

tions of decompo sing matter lying on the groundP—Replies : Y es

, 79 ;no , 45 ; doubtful , 39 .

(4) Have you Observed any connection between typho id fever and

putrid air, whether from ro tting vegetables in cellars,bad drains, un

ventilated living o r sleep ing ro oms,o r from any o ther cause —Replies

Y es, 90 ; no , 36 ; doubtful, 37 .

Ten towns report that typho id is a disease almo st entirely unknownam ong them ,

and they can assign no reason for this . In a table is giventhe m ortality from typho id fever in the urban p opulation o f Massachusetts during the last ten years , from which it appears that in 147c ities and town s o f m ore than 2 000 inhabitants the average annual rateOf m ortality from this disease was 07 5 5 per 1000 persons living ; whilstin 184 towns Of less than 2 000 inhabitants the average annual rate o f

mortality was s o much as per°

1000 persons living.

Typho id is m ore prevalent in the smaller rural towns than in the

large manufacturing town s, but the m ortality fro m all causes is higherin the latter. Dec ompo sing o rganic matter is considered in the rep ortas the pro ximate cause Of enteric fever.

Typhus—Grun "

I“ is o f Op inion ,

from his investigations into the epi

demic o f typhus in E ast Russia, in 1867 and 1868, that the disease is o fauto chthono us origin ,

and springs up where filth, po verty, and bad airprevail, and where vegetable and animal o rganism s find a suitable n idus,and develope a po ison which dissem inates itself further by way Of con

tagion .

Virchow}: has c onvinced himself that there are no suffic ient grounds3“ Dub lin Quart. Journ . o f Med. li, p . 480 .

1;‘V ierteljahrschr. f. Gerichtl . xiii, p . 2 03.

1: Virchow’s Arch iv,’ 53, p . 134.


fo r believing in the Spontaneous generation o f this disease,an

can , as a rule,b e traced to contagion .

Pastau’x‘ describes an ep idem ic ich prevailed in

am ong men ,and 3 19 in women ;

Nearly the half Of the cases fell bfive years . T he m o rtality, on thecreased with age . During the preo f enteric fever were less num

Pastau,typhus seem s to have something in comm on with relapsing

fever. G o od results were o btained from the c o ld water treatment .W ith this treatment the m ortality was per cent . during the firstweek, and per cent . in the sec ond week, agains t a percentage of

when the expec tant treatment was fo llowed.

Relap siugfever .—Tennent1' communicates a very

o f o bservations on the epidemic Of rela s ing fever inThe o rigin o f the epidem ic was trace to infectionFrom this fo cus the c ontagion spread, and reachedm iddle Of December. About 1 2 00 in al l

number when c ompared with the epidem icas many as cases o c curred. The disease

tions,since

the diseaseincrease innished

,a fact which was likewise

T he paper gives a full ac c ountdisease . The mortality was smalto tal o f 35 2 cases .Tennent did not Observe the Ophthalm ia described by Mackenzie

among the sequelae.

however, had o pportunity during this epidemic o fing this “ po st-febrile o phthalmia, ” o f which he gives a daccount .

the southern district

po ints to be bo rne in view by the san itary and o therresponsible fo r taking precautions against the disease and its

quences .

Centralblatt f. die Med. 187 1, p . 362 .

1'‘Glasgow Med. May, 187 1, p . 354.

I Ib id . , p . 347.


proportion to the cases, were nearly twice as many as the average experi

gnce Of the ho spital for thirty-two years would have progno sti

cateThis great ep idemic o f smallpo x was not c onfined to our own co untry

,

and though authentic information canno t be quo ted as to all the diffasion Of the disease in Continental E urope, facts enough are known to

justify the belief that, at least in the north-western parts o f the Continent , the power o f the ep idem ic was as great as here.

The lessons o f this ep idem ic , in reference to the value o f vaccination,

afford some very suggestive facts fo r c omparis on . In the chief townso f Ho lland, where vac c ination is non-c om ul sory, and where, as a rule,the children are long left unvac c inate in Hamburg, with non

c ompulsory vac c ination ; in Paris, where no t only vac c ination is nonc ompulso ry, but where also

,at least some years ago , there were strong

grounds for suspecting the quality Of much o f the current vacc ination ;—in al l these p aces the epidemic seem s to have raged with very much

more severity than even in London ; and Hamburg, which , thoughhaving but a tenth part Of our London po pulation , suffered nearly twothirds as many deaths as London ,

has now, under influence o f thisterrible suffering, been led for the first time to pass a law Of compuls oryvac cination.

T he pro ceedings taken by the Lo cal Go vernment Board fo r E ngland, with reference to the epidem ic Of smallpox , c onsisted in endea

vours to m o ve lo cal authorities to resist the diseas e in their respec tivedistricts by duly adm inistering, first and abo ve all

,as spec ially appli

cable to the case, the pro vis ions o f the vaccination law , and secondly,tho se provisions o f nuisance law which apply to al l dangerous infectiousdisease, and are meant to secure the iso lation o f the sick and the disinfection Of infected houses and things . The extensive diffusion Of the

disease in E ngland brought into prominence the evil results o f thegeneral want thro ughout the country Of ho spital accommodation fo rcases o f dangerous infectious diseas e .

The epidem ic brough t also into strong relief two popul ar errors withregard to re-vaccination . First, the erro r o f no t havmg it perfo rmed oneach person (irrespectively o f any immediate alarm Of smallpox) on hisattaining the age o f puberty, and sec ondly, the erro r Of seeking underpanic to have it erfo rmed indiscrim inately again and again . Under

the influence o f t ese two errors, Mr. Simon statesfl‘the first allowing

an indefinite accumulation o f po stponed cases, and the second givingswarms Of needless , or relatively needless, re-applicants, the demand fo rre-vacc ination, under al arm Of this great epidem ic , was such as medicalpractitioners c ould no t by any po ssibility at once meet without sacrificing the cardinal c onditions Of safe vacc ination .

It is stated in a re ortf that the necessity o f re-vaccination when thepro tective power o f t e primary vacc ination has to a great extent pas sedaway, canno t be to o strongly urged. NO greater argument to pro vethe efficacy of this precaution can be adduced than the fact that, o ut o f

Lo c . cit.

1‘ Repo rt Of a Comm ittee Of the Managers Of the Metropo litan Asylum District,

&c ., Pamphlet.

SMALLPOX . 489

upwards o f cases received into the ho spitals, only four well

authenticated cases were treated in which re-vacc ination had been properly perfo rmed, and these were light attacks . Further c onc lusiveevidence is affo rded by the facts , that all the nurses and servants o f theho spitals , to the number at o ne time o f upwards of 300 , who wereho urly brought into the m o st intimate c ontac t with the disease, whoconstantly breathed its atmo sphere, and than whom none can be more

expo sed to its c ontagion , have, with but few exceptions, enj oyed c omplete immunity from its attacks . These exceptions were cases Ofnurses or servants who se re-vac c ination , in the pressure o f the epi

dem ic , was o verlo oked, and who speedily to o k the disease ; and one casewas that o f a nurse who , having had smallpox previously, was not re-vaccinated, and to o k the disease a second time .

The medical Officer Ofthe Homerton FeverHo sp ital* (used during thesmall pox ep idem ic fo r smallpox patients) gives tables, embodying theexperience Of that institution, to dispro ve a very c omm on erro r

, viz .

that more vacc inated than unvacc inated persons are attacked by smallpox, and states that the real truth is that vacc inated persons , and byyaccinated persons he means only properly vacc inated persons, fo rm buta very small proportion Of tho se attacked by smallpo x. Lo oking at the

cases , divided into tho se o ccurring before and after puberty, he findsthe case stands thus with regard to patients treated in the abo ve-mentioned ho spital . Of 4 1 1 Of smallpo x vac c inated and unvacc inated, only17 had been vac c inated according to the standard o f the vacc ine institution ,

and 4 according to Mr. Marsou’s standard, i. e . that o f 4 1 1smallpox patients, but 2 1 had been vacc inated properly . T he pro

portion Of well-vacc inated persons attacked by the disease after pubertywas higher than under that age, but it was still true that well-vaccinated persons fo rmed but a small proportion Of the small pox cases . Of

549 cases o ccurring after fifteen , 3 2 onl y had been vacc inated acc ordingto the directions o f the vac c ine institution , and but I 3 acco rding toMr. Marson . Taking all the cases together, and a ssum ing the twostandards referred to as equally go o d, it was fo und that Of 1000 cases o fsmallpo x, 65 only had been efliciently vacc inated, the o ther 935 had beenineffic iently vac c inated.

Ano ther table is given showing the impo rtance Of quality in vac ci

nation,and illustrating the influence Of different kinds o f vaccinatio n in

determining the severity sho rt Of death . N o t a single severe caseo ccurred in a vaccinated child, and onl 7 well vac c inated children hadthe disease, and these in a very mil fo rm . Of 15 2 c ases o f severesmallpox o ccurring after twelve years o f age, 5 1 per cent . o ccurredamongst the unvac c inated, 2 3 per cent . am ongst the badly vaccinated,4 per cent . amongst the fairly well vaccinated, and amongst the wellvacc inated there was but one case .

,

A select c omm ittee of the House of Commons sat in the session o f

I 870 , and arrived at these among o ther c onc lusions :f—That the cow-

pox

affords,if no t an abso lute, yet a very great pro tection against an attack

‘Report of the Medical Officer o f the Homerton Fever Ho sp ital for 1871

Pamph let.1' Report. Vacc ination Act Blue b ook.


o f smallpo x, and an almo st abso lute pro tection against death from that

disease. That if the o peration be performed with due regard to thehealth o f the patient vacc inated, and with prOper precaution in o btaining and using the vacc ine lym ph , there need be no apprehension thatvac c ination will in '

ure health o r communicate any disease. Thatsmal lpox unchecke by vac c ination i s one o f the m o st terrible anddestructive o f disea ses ; as regards the danger o f infec tion, the proport ion o f deaths among tho se attacked, and the p ermanent injury tothe survivors , and therefo re that it is the duty of the State to endea

vour to secure the careful vaccination o f the who le po pulation . As ac onsequence o f the recommendations o f the select comm ittee

,the

Vacc ination Act, 187 1 , was passed, the pro visions o f which must beknown to the readers o f this Retro spect . ’ T he bulky repo rt o f theselec t comm ittee contains a mass o f extremely valuable m atter re

lating to vaccination and re-vacc ination,including all that can be said

against the o peration .

S curvy—Much interesting matter has been published relative to a

scorbutic epidemic which prevail ed in Paris during the winter o f thesiege of 1870 As regards the etio logy o f the disease, Dr. 0.

Berger is o f op in ion that scurvy was brought abo ut by the fo llowingcauses z—Depressing mental influences ; undue bodily exertion, as wellas want o f exercise ; o vercrowding ; co ld ; alteration in diet, m o re

espec ially the want of fresh vegetables ; want o f fo o d, and this was thechief cause o f the epidem ic . An insufficient quantity o f fo o d ac ted

,

however, as a redispo sing cause only, and was incompetent to inducethe disease in t e absence o f spec ial c onditions, no tably the withdrawalo f fresh vegetables . E ven with this in o ther respects best o f diets

,

lack o f fresh vegetables induced scurvy . As regards the quantity o ffo od it i s worthy o f no te that the theo ry which asserts that the use o fsalt meat produces scurvy, receives no suppo rt from the facts o bservedduring the siege ; a diet of fresh meat induced scurvy where freshvegetables were withheld, even when every o ther hygienic conditionwas perfect . Acid fruits were found to replac e fresh vegetables .Wounds received whilst fightin were no t roved to predispo se towardsthe disease. Chalvet found t 6 cause of scurvy to be inanition

,in

conjunc tion with co ld. It is also asserted that the great benefit derived from the use of green vegetables and fruits arises from this, thatthe po tash salts c ontained in them readily split 11 in the o rgan ism intoacid and base, whilst the pho sphate, nitrate, an chloride

,being much

more stable,canno t replace the less stable po tash salts

,

Delpecht found that an abundant diet o f fresh meat didno t wardo ff the disease where fresh vegetables were withheld, and as serts that thedeprivation o f a vegetable diet is the so le determining cause o f scurvy.

Dwellers in marshes—Prof. Preste1,1: o f Emden, recommends rainwater for use among the dwellers in marshes

,where, as is well known,

it is Often next to impo ssible to pro cure go od drinking-water from wellsAnn . xxxv, p . 2 97, and xxxvi, p . 2 79. Gaz. vii i (xvii i), 187 1,

6, 9, 14, 16, 1 7, 18. Schmidt’s c liii, p . 82 .

1 Loc . cit.

1 V rtljhrsschrft. f. Gericht. N.F., xvi, p . 336.


effects produced by petro leum are a peculiar action on the brain andheart . The lighter portions o f the o il , known as petro leum ether o r

benzo line,may b e used as an anaesthetic . It is known that wo rkmen

who are engaged in petro leum warehouses suffer severely from inhalation o f the vap ours ; and certain precautions are necessary in o rder towork safely with petro leum .

E ntozoa in rela tion to public hea lth and the sewage question .—Dr.

Spencer Cobbo ld* is o f o pinion that the utilization o f sewage fo r thepurpo ses of irrigation greatly c ontributes to the diffusion and growth o fparasites in man and the domestic animals . He mentio ns facts whichseem to render this not merely a hypo thesis ; the c ommon o ccurrence o f

ento zoa, the difliculty o f diagno sing the diseases caused by them and the

enormous number o f o va which they produce. Parasites once introduced into a lo cality can by means o f sewage irrigation become ende

mic . In regard to the enormous reproductive powers o f ento zo a,he

mentions the case o f a girl under treatment for bilharzia haematob ium ,

who se urine daily contained so many as o va o f thisparasite.

D isinfection—Pro f. Hoppe-Seylerf has made a valuable c ontributionto our knowledge o f putrefac tive and fermentative pro cesses , and hehas also investigated the influence which several reputed disinfectantsexert upon these pro cesses . Our review will embrace this latter portiono f the subjec t only .

After reference to Pettenko fer’

s well-known views as to cho leragerms, the autho r asserts that

,altho ugh deodo rants, as

, e .g . sulphateo f iron, destroy the ill-smell ing roducts o f fermentation and putrefaction, it must no t be suppo se that the infec tive materials o f suchdiseases as cho lera and typhus are thereby necessarily destroyed, andthat in carrying out disinfection we must no t rest c ontented withmerely destroying bad smells . He is o f o pin ion that metallic salts actas dismfectants chiefl by recipitating ferments, and along with thesethe lower organisms so . e has pro ved that 1 -2 0th o f green vitrio lsuffices to prevent all development Of infuso rial life in a so lution ; buti t i s questionable whether the ferment and the o rganism s are re

spectively so changed and destroyed as to be incapable o f showing theira ctivity renewed undef altered c onditions . As regards carbo lic ac id,Ho ppe-Seyler finds that the destruction o f the lower o rganism s isadm irably achieved by the use o f a very smal l quantity of th is agent,but that the prevention o f fermentation demands the emplo ent o f a

much larger amount o f it . One per cent . o f carbo lic acidwil effectuallyput an end to o rganic life, but two per cent . is required to preventputrefactive changes .Sulphurous ac id gas appears to the autho r to be the m o st effective

agent for destroying germ s in the air. Rather less than 14—3 ounceso f sulphur burn t in each 100 cubic feet of the space to be disinfec ted entirely prevents the growth o f fungi . These quantitieso f sulphur give one and two vo lumes per cent . respectively o f sulphuro usac id gas

it Med. Times and Gazette, ’ 187 1 , i, pp . 93 , 2 15 , 236, 363 .

1‘Medizin .

-Chem . 187 1, p .

’

56 1 .

DISINFECTION. 498

Some further useful and new info rmation on this subjec t is als o c on

tained in a paper by Dr. Zapo lskyfi“

The Chem ical So ciety o f Berlin? has issued the fo llowing in structio

ps

ufo r disinfection . They are so valuable that we give them almo st

in u

E xcremeutitious matters and p rivies .—For commodes

,so lutions o f

permanganate of po tash or o f carbo lic acid are to b e used,also fo r pus

basins and chamber utensils , rinsing with carbo lic ac id so lution,

leaving a little o f the so lution in the vessels after the o peration . Fo rspitto ons, carbo lic ac id p owder. Fo rnight sto o ls , carbo lic ac id p owder ifthey are to remain unemptied

,and so lutions o f permanganate o f po tash

if they are emptied immediately. For c lo sets with separate receptaeles , carbo lic ac id powder to the so lid, so lution o f carbo lic ac id to theliquid, excrement . Fo r water-c lo sets use carbo lic ac id water. Fo r

privies c ommunicating with ces s -p its use carbo lic ac id powder, so lutions of ch loride o f m anganese, green vitrio l, o r o ther metallic salt ;applying the disinfectant to the surro unding so il also . For priviesc ommunicating with dung pits, sprinkle with carbo lic ac id powder or

with a so lution of carbo lic ac id in water. Fo r sanitary p ipes usecarbo lic ac id water. Fo r latrines in c amps and barracks use lime

,

gypsum,o r

, at all events,earth

,and change the site o f the latrines

frequently . Dung-heap s are to be treated with carbo lic ac id powder.

Urinals are to be treated with carbo lic ac id water and so lution o f

chloride o f lime (we have found chloride o f lime o f little use in deo dorising urinals ; the chlo ride so on ex

pends itself in liberating nitrogen

from urea . Spent charpie, int, bandages , &c . , should be c o l

lected in vessels o f tinned iron c ontaining permanganate o f po tash o rcarbo lic ac id, and then burnt . If the abo ve are thrown into dust-bins

,

chloride o f lime is to be employed. Straw, hay, and the like, fromtransp orts fo r the wounded, and so aked mattresses no t again to be

used should be treated with chloride o f lime, and burnt as quickly aspo ssible . Animal refuse from slaughter-ho uses and lairs are to be

buried deeply and c overed with quicklime o r with ch loride o f lime.

E nc lo sures—These inc lude sick-ro om s, railway carriages, and

waggons (and things used fo r transports o f every kind) , c owstalls

(espec ial attention must be paid to the mangers) , workro oms infactories, scho o ls , prison-cells , sentry and watch . boxes , lavatories ,barracks, living-ro oms, urinals, operation-ro oms, dead-houses, warehouses fil led with animal matter

,slaughter-houses, and ship -decks .

T he flo o rs o f these are to he sco ured with carbo lic acid water, andthe walls and ceilings lime-washed with carbo lic ac id and lime, and theair is to be purified by the evaporation of wo od-vinegar, or carbo licacid (from the powder) .If the ro oms are unused—and only then is an actual disinfec ~tion o f the air feasible—the flo ors are to be washed with a so lutionof chloride o f lime o r o f hypo chlo rite (liq . sodae chloratae, & c .) o r

a so lution o f chloride of manganese. Place about the ro om or o thervessels containing chloride o f lime with either hydro chloric or acetic

Medizin .-Chem p . 842 .

1‘ Dent. Ztschr. f. Staatsarznkd,

’n. f. xxix, p . 164


acid, o r strong nitric ac id,o r nitri c ac id and p ieces o f tin-fo il .

Sulphur may b e burnt (ro ll brim stone is best) in earthenware vessels .After fumigation use free ventilation and sprinkle carbo lic ac id wateraboutOp en spaces . Co urts, market-places , Open abatto irs

,cemeteries

,

battle-fields , and deserted places Of rendezvous here inc luded.

Ab o ve all things, remo ve the causes o f danger’

(putref ing refuse,c orpses, &c . burying such matters, o r c overing them wit chloride o flime

,lime

,o r earth . Further, larger surfaces are, when p o ssible, to

b e watered with a so lution Of chlo ride o f manganese. The sowingof plants o f rapid growth is very advisable .

Wa ter.

—Drinking water is best rendered harmless by previous bo iling. Fail ing this , permanganate o f po tash may be added till the wateris just tinged by the salt.Turbid water, or water that becomes turbid on standing, may be

c larified by the addition Of a little alum o r soda .

Carbon filters remain active onl y when they are frequently calc inedwith exclusion o f air.

F lowing or stagnant water.—Sinks, gutters , conduits o f all kinds

,

po o ls, &c . ,

are to be sluiced with as much water as p o ssible, and to befrequently treated with the fo llowing agents : carbo lic acid, quick lime,chloride o f magnes ium, and tar (Suvern

’

s m ixture, see below) , alumsalts, chloride of manganese

,and o ther metallic salts .

B ody and bed-linen,artic les of c lo thing,

(

r

ife—Linen must be sprin

kled immediately after use with carbo lic aci water, and then immersedfo r some time in bo iling water.

Mattresses , uniform s, and artic les Of c lo thing, are best hea ted in an

o ven to 2 1 2°to 2 58

° Fahr. ,and afterwards beaten . When thi s canno t

be done, the actually infected articles are to be burnt,and the rest

so aked in carbo lic ac id water, and then dried in a warm ro om .

M en and living anima ls that have c ome into personal c ontac t withinfected matters—Wash the hands in a so lution o f permanganate o f

po tash . The animals are to be sprinkled all over with carbo lic ac idwater and espec ially on the soft parts .Corp ses which are to be remo ved to a dis tance are to be Sprinkled with

carbo lic ac id water, and to be wrapped in clo ths soaked in so lution o f

chlo ride o f lime ( 1 inWhen po ssible the abdomen is to be Opened—a small opening will

suffice—and so lid chlo ride o f lime inserted.

Wounds—The treatment o f these must always be left to the surgeon.

It may, however, b e remarked that so lutions o fp ure permanganate o f

p otash and pure carbo lic ac id sho uld alone be used.

Directions for the prep aration of the diswzj ect'

mg ma teria ls—So lutions

o fp ermanganate ofp o tash shoul d c ontain 1 part o f the pure salt in 100

parts o f water,o r

,if the c rude salt be used, 5—1 0 parts in the same

quantity o f water. It acts, in so lution, as a disinfectant,but acts only

o n the surface o f so lid masses .Carbo lic a cid water is o btained by disso lving 1 part o f pure crystal

lized carbo lic ac id (liquefied by immersing the vessel in warm water)in 100 parts o f water. Crude carbo lic acid, the strength of which

REPORT ON PUBLIC HEALTH.

The Infant Life Pro tec tion Act, 1872 , c ontemplates the perio dicalexamination and licensing o f all houses where baby-farm ing is carriedo n as a practice, and is intended to in sure for infants sent o ut tonurse, pro er fo od and attention ; and, in the event o f death an

inquest is directed to b e held.

T he Factories Steam Whistles Act requires the san c tion o f the lo calsanitary autho rity fo r the use o f steam whistles and trumpets , in o rder

to prevent annoyance in quiet neighbourho ods .The Act o f 1872 to amend the law for the prevention o f adul

teration o f fo od and drink and o f drugs is a mo st impo rtant o ne .

By the o ld statute o f 1860 it was made penal to adulterate artic les o ffo od and drink with substances injurious to health . By the PharmacyAct of 1868, the pro vision s o f the abo ve statute were extended to drugsbut the adul teration o f drugs was deemed Of such importance to thec ommunity that all admixtures o f drugs were dec lared to be adulterations . These Acts were entirely ino perative, and no t being obligato ry,were never put in force. T he recent statute amends the definition o f

adulteration, and enacts a penalty for the m ixer, and the person whoo rders admixture, as well as for the vendo r o f adulterated artic les o ffo od, drink and drugs . It is thought that the law now stands thus,1 . All admixtures o f drugs are adulterations injurious to health . 2 .

Fo o d and drinks are adulterated when they are m ixed with substancesinjurious to health, and also when substances are added fraudulentlyto increase weight and bulk . 3 . Lo cal authorities are empowered toappo int analysts

,who must have competent medical, chem ical and

m icro scopical knowledge, and it is suppo sed that the Lo cal G o vernmentBo ard can c om c l recalc itrant lo cal autho rities to apppo int analysts .The Public ealth Ac t

,1872 , is a mo st important measure, pro

viding fo r the c onstitution o f urban and rural sanitary districts,authorities and officers ; bringing the who le o f E ngland under sanitaryregime, and giving the central Lo ca l G o vernment Bo ard a direc t vo icein

, and c ontro l o ver, the pro ceedings o f the lo cal sanitary autho rities .It is expected that this statute will speedily b e supplemented by a

conso lidation o f sanitary law—a refo rm much needed.

I N D E X.

ABDOMINAL aneurism (Durham), 205tumour, c ases Of (Dickenson), 166Abortion, case o f (No eggerath), 402caused by retroflexion of the uterus

(Ph illip s), 402Ab scess, intra-cranial, treph in ing for, 268of the bra in, titles of papers o n, 93of the lung, 122—3Ab sorption, by the unbroken skin (Ausp itz, Neumann, Rohrig), 3—4influence of muscles on (Genersich), 3influence o f nerve centres on, 4list of authors on subjects connected

with , 5of lymph by tendons (Genersich ,Lesser, 3—4o f so lids from serous cavities (Ausp itz , Neumann), 3Accomm odation, paralys is of, in diphtheria (Hutch inson), 104Ac id, c arb o l ic , action o f, internally (Salkowski) , 446do ., in ch o lera , 48—50do ., p o isoning by, 445c arb on ic , am o unt Of elim inated fromthe skin (Aub ert) , 13do .

, tens ion of, in b lo od and lungs(Wo lffb ey), 15hydro cyanic , action o f (Amory,446—48do ., chem istry of (Miahle), 448do ., detection o f (Almen , Preyer), 454nitric , ca ses o f po ison ing by, 442sulphuric , c ases o f p o iso ning by, 441sulphurous, actio n of, o n germ s , 492

Ac ids , cases of po isoning by vario us, 442Ac onite, antagonism o f, to digitalis(Dob ie), 440Aconitine, on (Duquesnel, 468

Acupressure, a new p lan of us ing (Lucas),198

on (Pirrie), 197Adams, case o f extra-uterine foetation,Adam s (J . dislo cation o fwrist, 248

exc is ion o f wedge o f b one at knee,224

fracture of head of radius, 258

Adam s (J . transition of testic le intoperinaeum , 281

Adam s (Mr. fracture o f skull iii ach ild, 266sub cutaneous divis ion of neck o fth ighb oue, 234

Addison’s disease, cases o f (Laschkewitsch , Tuckwell, Payne), 76do ., redc orpus cles in Laschkewitsch), 8do ., titles o f papers on, 76Adenoma , lymph (Murch ison), 111Adenopathy, b ronch ial, o n (Guéneau deMussy) , 110Adipo cere in a ranula (Tay), 284

ZEgoph ony, o n (Stone), 107Affieck, cases of dilatation Of the stomach,15 3

case o f sh oulder presentation, 414Ague (see fever, interm ittent), 45Ahl feld, determ ination of the s ize and

age o f ch ild before lab our, 395A ikm an, case o f doub le uterus and va

gina, 371Air and ra in, on, 491

Album ino id com pounds in mus cle in

tetanus (Danilewsky), 27Album inuria, 167—71during pregnancy, on, 397in smallp ox (Cartaz), 63in syph ilis in a child, 66

Alco ck, ovario tomy in ch ild, 301Alcoho l, action o f (Parkes, 463

do ., in fever, 464do . , o n temperature, 464

elim ination of (Subb otin, Dupre,18, 464

use o f, in pneum onia, 464Alcoh o lism , o n, 491

Allbutt (Clifford) , cases of tetanus,98

effects o f strain on the heart, 132

effect of exerc ise On the b odily temperature, 15 , 40

emac iation in typh o id, 52h isto logy of bra in, &c ., in hydr0pho

b ia‘

, 42

Almen, detection of hydro cyanic acid,454

498 INDEX .

Alopec ia, general, case of (Crisp), 184on (P incus) , 184Am enorrh oea, 372Amm o nia, case o f po ison ing by (Stevens on), 442Amm on ium , ch loride of, action of, 462

Amnes ia, case o f (Bristowe), 87Amn ii, liquor, urea in , 17Amn ion, on the, in relation to foetal mal

formations (Furst), 393Amory, action of hydro cyanic ac id, 448Amputation after exc is ion o f the hip , case(Jackso n), 221at the h ip

-j o int, 211at th e knee-jo int (E rich sen, Staples),212—13death -rate after (Callender) , 2 11in senile gangrene (L ister, Morgan),213

o f the fo ot, mod ification o f (Sto kes),213

re at the hip (Otis), 212recurrent haemo rrhage after, 211

snpra-condylo id, Ofth igh (Sto kes) , 212

through femora l c ondyles (Richardson), 212Amputations, ankle-jo int, on (Smith), 213in utero , o n (Barnes), 393results o f (Benny) , 213Amyl, n itrite of, as antidote to strychn ine(Gray),do . , on (Wo od, Jones, Brunton),

466—7Anaem ia during pregnancy (Gusserow) ,397

Anaesth etic s, o n, 193—465Analges ia in hysteria (Ro senthal), 80Anchylo s is, exc i s ion o f the elb ow for,2 16—8o f knee, exc is ion o f wedge o f b o ne in

(Mo rton, Adam s , Watson) , 223- 2 5

do sub cutaneous o steo tomy in

(L ittle), 225o f the lower jaw, operation fo r (Maas ,

Bo ttini), 230Anderson (McCall), case o f haematidro sis ,183

cases o f elephantias is, 182cases o f skin disease, 174on tinea favo sa, 185

Anderson (Mn ), o n ep iderm ic grafting,335

Andrei, on Caesarean section, 412

Andrew, case of rh eumatism , 74Aneurism, at the ro ot of the neck, doub leligature in (Lane), 202axillary , traumatic (Gay), 202axillo -sub c lavian (Gay), 201—202c lo se to the heart, diagno s is of (Balfour), 149

Aneurism , dissecting, case of (B150

false, cases of (Spence), 210fem oral, cases o f, 208fem orO-

p opliteal, temporary deliof fem oral in (Stokes), 208injection o f ergotin in (Duto it),l ist o f papers on, 150—5 1o f the ab dom inal aorta,press ion in (Bryant) , 206do ., c ompression in (Durha205—7o f the arch o f the aorta, ligature 0

c omm on caro tid in (Heath), 201do . , s imulating innom inate (Heath)202

of the aorta , diagno s is o f, w ith th

laryngo sc ope (Johns on), 149of the c ommon caro tid artery, ligatur(Lane, Gamgee), 200of the c oro nary artery (Crisp), 149of the heart, c ases o f (Murch isonTo wnsend), 139of the innom inate , apparent curt

(Morgan), 201of the m itral valve, case o f (S imon)141

of the vertebral artery, traumati

(Ko cher), 202popliteal, b ursting into knee-j o in(Jam ieso n), 209do ., cases o f, 209

do ., c ompress io n in, 209do . , flexion in , 209

do ., ligature in, 209sub c lavian, compress ion and l igatureo f innom inate in (Bickersteth), 201surgical treatment o f (Ho lmes), 198traumatic , after reduction o f dislo ca ~

tion o f humerus (Morgan, Rivington)248

treatment o f (Bryant), 199Angina p ecto ris (Mo inet), 146pharyngo

-s crofulous (Isambert), 151ul cerative (Lubanski) , 15 1Angioma muco sum pro liferum, 189—90

Animal paras ites affecting man, 77—9Animals, infec tion from po ison of (list 01authors on), 42

Ankle, amputation at the (see amputa

tion)dislo cation at the (see dislocation), 255Annandale, case of haem orrhage fron

internal wound o f oeso phagus, 287

case o f injury to the head, 267exc ision o f the elbow in anchylosis;216

exc is ion Of the hip -jo int, 220intestinal Ob struction from hand oi

lymph , 298

500 IND

Asthma, b ronch ial (Leyden), 117do . , titles o f papers o n, 117

Astigmatism after cataract operations(Wo inow), 347Astragali, b o th , exc is ion of (Lund) , 226Astragalus, c ases o f exc is ion o f, 226

Asymm etry, on a c ase o f foetal, 427Ataxy, lo com o tor, case o f (Greenh ow,

Cayley), 98Atheromatous tum ours o f neck, removalo f (Schede) , 243Atlee (Dr, W . fibro -cystic tumour o f

uterus s imulating ovarian, 381

do . , rem oval o f cystic tumour o f

neck, 237c alculus in femal e, 278cases o f ovariotomy, 301, 390on a new c lamp , 305

perito neal inflammatory cyst simulat

ing ovarian tum our, 304

Atrop ine, antagonism o f, to morph ine(Firmy), 439do ., to physo stigmine, (Fraser),

434

effects o f, on heart (Schm iedeberg),10

do ., on o cular tens ion , 338

do ., on pupils o f p igeo ns , 449Aub ert, amount o f c arb on ic ac id c lim inated from the skin, 14

Auchenthaler, c o inc idence o f meas les ands carlet fever, 60

Aus cultation in diagno sis o f sex o f ch ild(Hutton), 396Ausp itz, ab sorption o f so l ids by serous

membranes, &c ., 3

Aveling, cases o f post-mortem parturition,

410

on transfus ion, 380—419Axilla, m edul lary c ancer o f (Durham),244

Bacon, case of idiotcy, 88Bacteria, development of (Bastian, Sanderson, 2

development o f, in various so lutions(Sanderson , Bastian) , 36in b lo od (Nepveu , 36—37in skin, in smallpox (Weigert) , 68presence of, at h igh temperature

(Blake), 2Baginsky, cases o f aphasia, 87Bahrdt, p o isoning w ith nitro -benzo l,Bailey, trismus nascentium, 428

Baker (Morrant), ligature o f the comm on iliac artery fo r h sem orrhage, 207Balfour, diagnos is o f aneurism near theheart, 149

pre-systo lic murmur, 131

INDEX.

Béhier, case of p leuritic efi usion, 113Belina, c ase o f transfus ion, 419Bell, case o f invers ion o f th e uterus, 418

case of tracheotomy for croup , 106

Bell (Dr. Jo seph), intestinal ob struct ionw ithout s ickness, 295on m ode o f removing the mamma,234

o steo id cancer o f ulna , 244o n ves ico -vaginal fistula, 282Bell (Royes), exc is ion of phalanx o f

thumb , 218

Belladonna , antagonism of, to op ium(Little), 439eruption after application of, 423

Beneke, s ize o f arteries , 8Bennett (E dward), Operation for unun itedfracture o f t ib ia and fibula, 2 59removal o f fo reign b ody from the

larynx, 321Bennett (J. Henry), ab sorption o f po isonsby unb roken skin, 37action of mercury o n the secretion of

b ile, 463Bennett (Henry), case of cancer o f uterus,382

Bennett (Risdon) , c ancer of lung, 124Benzine, use o f, in co ugh , 467Berger, cases of eph idro sis unilateral is,183

cases of premature gray hair, 184on s curvy , 490

Berkart o n emphysem a , 116

Bernhard, paralysis of arm after dislo

cation, 247emb o lism , 135

e o f gases in p lacenta,changes in the baro

o n vital phenomena,

ion o fcuneifo rm b ones,

o f the m outh , 239

removal o f scro tal tum our, 243

Biesiadecki , c orpusc les in b lo od in syphi

lis , 65

Bifii, ino culation o f tub ercles , 38Bile, action o f mercury on the secretionof (Bennett), 463co lourless, on (Rob in), 165Bile-ducts , affections o f the, authors on,

&c ., 164

Biliary ac ids, detection o f, in urine(Strassburg), 17

501

Biliary calculus, case of, 164concretion caus ing ob struction (Clark),295

fistula , case o f, 164Bil lroth , arsenic in multiple lymph oma,244

ench ondroma o f the rib s , 241resection o f the oesophagus, 285o n traumatic fever, 311

Binz, ac tion o f quinine on b lo od-corpuscles, 7Birch -Hirsc hfeld, tum our removed fromthe abdom inal cavity, 189Bird, hydatid cyst of lung, 125Birkett, remova l of exo sto sis from firstrib, 240

Bizzo zero , on certain large corpuscles inpus , 34

Blache, on rickets, 428Bladder, c ase o f doub le, 371

c ase o f ulceration of the, in pregnancy,‘

399

extrovers ion o f the (Maury, Ash .

burst) , 275female, exfo liation of the (Wardell,

400

invers ion o f the (Cro ft), 275lith o tri ty with atony, o f the (Maliejowsky), 276rem oval o f p iece of b one from the

(Thompson) , 277resistance of the sph incter muscle ofthe, 20

rupture o f the (Stokes) , 277sto ne on the, ch o ice of operations for(Thompson), 276w ound o f, w ith fracture of the pelvis(Bell), 277Blake, diatoms growing at h igh temperature, 2

Blas, on detection o f p icro toxin, 455Blaser, on ap om orph ine, 469Bloo d, a c iliated haem atozoon in the

(Boyd-Mo ss) , 7a c o llo id fluid w ith difi

'

usib le con

stituents (Marc et) 7(s ee leuco cythaem ia) 69(s eem icro cythaemia), 70alkaline, in leucaem ia (Mo sler) , 8analys is o f the, in s curvy (Chalvet), 8ashes of the, o n (Jarisch ) , 6bacteria , &c ., in (Sanderson, Lo storfer,Ferrier, Bastian, 36

c o agul ation o f the, on (Schm idt,S chifi

‘

er, Bo ll), 7c o louring m atters o f the (Struve), 5corpusc les, act ion o f b ile o n (Jurasz), 6co rpusc les, auth ors on, 8c orpuscles, passage o f, through thewalls of the vessels (Norris), 34

502 INDEX .

Blood corpuscles, red, in Addison ’

s

disease, state of (Laschkewitz), 8c orpuscles, red, s ize of, in septicaem ia(Manassein), 6c o rpusc les, state o f, in case o f b ronzingo f skin (Las chkewitsch ), 76c orpuscles , wh ite, action o f quinine o nthe (Geltowsky, Kerner, Binz) , 7c orpusc les , wh ite, glycogen in, wh i lem ob ile (Hoppe-Seyler), 8corpuscles , wh ite, o rigin of pus from ,

on (Duval), 7corpusc les on the structure of the

wh ite (Richardson) , 6crystals, on the (Preyer, Brond

geest), 5current in musc le (Hafiz , 278exam ination o f, in scurvy (Chalvet),75filaria in the (Lew is), 6fungi in the (Lo sto rfer), 7list o f auth ors on, 8pecul iar c orpus cles in the, in syph i lis(Lo storfer, Stricker), 8pressure, action of strychnine on

(Mayer), 10do ., influence of nerves ” on (Mis scher), 9quantity of oxygen in, in various ar

teries (Math ieu, D’

Urb ain) , 13rap idity o f the current o f the (Cyon,

9

sarc inae in the (Lo storfer, Ferrier,Bastian), 36spectro scopy of (Sorby), 459stains , on detection o f (Sonnenschein,

458—59tran sfus ion of, on, 329

vessels, developm ent o f the earliest(Klein), 7Boehm , on action of digitali s , 470

Bo elt, case o f oedema glottidis, &c .,

101

Bogo lowsky, ino culation of tub ercle. 38Bo isseau, aph as ia in interm ittent fever, 45Bo ldyrew, h isto logy of resp iratory mu

cous m emb rane, 11

B01], c oagulation o f the b lood in a

ch ick , 7Bond, o n gonorrhoeal rheumatism , 282

Bone? disease in hereditary syph ilis(Wagner), 307

g3unsh ot injuries of (Mac Cormac),

2 4

rem oval o f p iece of, from rectal fossa(Thompson). 300

-

z

removal o f tumours from (Paget),42

Bones , compo s ition o f, Wh ilst improperfood was given (Weishe), 29

Bones , delayed union o f (Callender) , 2 56o ss ification o f the marrow o f (Demar!

quay), 332Borel, amb er m outhp iece o f pipe in orb it,363

Borgioni, treatment of ep ididym itis byice, 282

Bo tkin, on ch o lera, 47Bo ttini , operation for anchylo sis of thelower jaw, 230

Bouchut, case o f hydatids of the liver,163

o n p leuritic effus ion , II3

Ophthalm o sco p ic appearances in acuteaffec tions o f the nervous system , 90treatment o f diphtheria, 106

Bo uvier, action o f alc oho l in fever, 464Bradley, case of syphilitic renal drop sy,168

syph ilis w ith album inuria in a ch ild,66

Bra in, ab scess o f the, titles of p apers on,

93

cas es of gunsh ot injury to the (Cohn),352

changes in newbo rn ch ildren (Jastrowitz), 91disease, Ophthalmo sco pe in, 90—91do ., treph in ing in (Pepper) , 268diagno s is of syph ilitic disea se o f the

(Rees), 65effects o f galvani zing the (Fritsch ,hydatids in the, cases (Reeb), 78inflammation of, on idipoathic (E lam) ,91

injury to , affections o f lungs fromBrown -Séquard), 269do ., lo cality o f, causing convuls ions(Callender) , 268so ften ing o f the, c ases of, and titleso f papers o n , 91—93temperature o f, w ith exc itation o f seno

s ory nerves, 22Brake], on peristals is, 16Branco , cases of ab sence of the vagina,370ras ch , treatment o f diphtheria, 106raun, case o f deform ed pelvis, 410Bread , relative value o f different kindsof (Meyer), 18Breast, can cer of, statistics of (at Bradford), 233m ode of removing the (Bell), 234removal, &c ., o f, 233—34statistic s of rem oval of tum ours of

(Syme), 233Breeding, experiments on (Galton), 3Breisky, case of pyometra and pyoko lpo slateralis, 370

504 INDEX .

Calculus vesicee in the female, opera

tions for, 278—79Calvert (Crace), on development of bac

teria, &c . , 2

Campb ell, case o f doub tful typhus, 56vom iting in pregnancy, 400Camphor, action of, on heart (Heubner),469

m onob rom ide of (Hammond) , 469Cancer, medull ary, of axil la (Durham),244

o f breast, 233—34of female genitals , sudden death in

(Barnes), 383o f th e heart (Payne), 139of imperfectly descended testis, references (Arnott), 281o f l iver, cases o f, 163o f lungs (Bennett, Arnott, Sparks ,Waters), 124of penis, ca ses o f, 275o f the uterus, cases of, &c . , 382—83o steo id, o f ulna (Bell) , 244Canton, cas e o f exc is ion o f the knee, 222exc ision o f the ankle, 226rem oval o f b o th superior maxi llae,230

Capsules, supra -renal, changes in , 76Carb o lic ac id in cho lera, 48—50do . , internal use of (Salkowski) , 445do ., p o isoning by , 446spray, on (Lister), 195Carb on, oxysulph ide o f, on (Radziejewski), 444Carb onic ac id, amount o f, elim inatedfrom the skin (Aub ert), 13do ., tens ion o f, in lungs and b loo d

15

oxide, po isoning by (Zuntz, Donders ,443

Carc inoma (see cancer)Cardiac murmur, c o inc idence o f, w ithperiod of heart’s action , on (Jacob son),129

do . , pre-systo lic (Barc lay, Balfour),

130

do ., on , 129—34do ., titles o f papers on, 13 4Cardio -sphygmograph , on a (Garrod), 9

Carmalt, on keratitis, 33Caro tid artery, c omm on, l igature of, inaortic aneurism (Heath), 201do ., case o f ligature o f the (Lane),202

do ., internal , case of rupture of (Verneuil), 84Carpenter (Dr. Alfred) , origin of scarletfever, 60, 487Cartaz, on urine in smallpox, 63Carter, paracentes is in p leurisy, 113

Carter (R. repo rt on Ophthalmicm edic ine and surgery, 337Casein o f m ilk, m o rph o logy o f 423

Cataract, extraction o f, w ith out o peningthe capsule (Pagenstech er) , 345do ., m ode o f (Wecker) , 344do .

, on (Maz zei) , 343Operations,astigmatism after(Wo inow),347Catgut ligature, on antiseptic , 195Catheter, a new self-retaining (Wright),271improved , flexib le, for retention in

b ladder (Thompsan) , 271verteb rated (Squire, Sayre), 272Catheterism , fo llowed by fata l urethralfever (Banks), 271

Caussé, c ase o f Caesarean sectio n, 413Cayley, ca se o f lo c omotor ataxy, 98

case of paralys is agitans , 97Ceradini, action o f heart o n resp iration, 11

effects o f heat o n the heart, 9

Cerebellum , cases of tumours o f the, and

titles o f p apers on, 92- 93

hydatid cysts of the (Evans, Pul lar),93

tubercle o f the (Cordier, Jackson),92

Cereb ral disease, diagno sis of syphilitic(Rees), 65do ., treph ining (Pepper), 268hem ispheres, effects o f

the (Frits ch , Hitzig), 22mechan ism o f speech and thought

(Bro adbent) , 84softening, cases of, 91—92do . , titles o f papers on, 93tuberc le, c ase o f (Heischmann), 92Cerebritis , iodiopath ic, on (E lam), 91Cerebro -sp inal meningitis, titles o f paperson, 44—45sp inal meningitis on (Eulenberg,Ko tsonOpulo s, Russel), 43—44Chalvet, analys is o f the b lo od in scurvy,8

on scurvy, 75Chamberlain , o n acute atrophy of the

l iver, 160Charco t, o n hysterical contraction of thel imb s, 79on irri tative spinal lesions , 95Charrier, uterine injections for chronicmetritis, 392

Char

geris, po st

-febrile ophthalm ia, 5 7,48

o n relapsing fever, 486Chautreuil , on cancer of uterus in con

nection w ith labour, &c ., 411

on uterine express ion as a means ofdel ivery, 409

INDEX.

Chauveau, c ontagion“

due to so lid partic les, 35Cheadle, on c irrh o s is of the liver, 162Cheiloplastic operation, on Zeis ’ (Sto kes),330

Chest, fourfo ld gunsh o t injury of, re

covery after (Lorinser), 264Chevalier, on petro leum , 491

Ch icken-

pox (see varicella), 60—62Chiene, Obturator hernia, 290Ch ild, determ ination o f age and s ize of,b efore lab our (Ahlfeld), 395sex o f, determ ination of, in utero

(Hutton), 396Ch iso lm dislo cation of the sem ilunar b one, 248Children, jaundice in new-b orn, 432

Chloral hydrate, antagon ism o f strych

nine to (Oré), 439do ., in ch o lera, 50do . , on the employm ent of, 464

do . , po ison ing w ith , cases of, 449Ch lorides , on use of (Rabuteau) , 462Chloroform c omb ined w ith m orph ine,on the adm inistration of (Haward),193

Chloro s is , on (Wade), 372

(Virch ow) , 373Cho lestearine in calculus (Dunc an), 279Cho lera, burning o f straw , &c ., in, 51

carb o lic ac id in. 48- 50

cause of , on, 481

ch loral hydrate in, 50c ontag ion, 481difiusion o f, in India (Pettenkofer) ,477ep idem ic at Zurich , report on (Zehnder), 480germs, action o f dis infectants on ,

492

influence o f ground water on the

Spread o f (Pettenk ofer), 477on n itrite of amyl in (Brunton), 467on the spread o f (Radc liffe), 472—77op ium in , 50

organ ism s in, 482

propagation, symptoms, treatment,

&c . , o f, 47—52quinine in, 48 -50

rep ort on (Cunn ingham ), 479titles of papers on, 51—52Chorea, ca se o f facial paralys is after

(Buzzard) , 81case o f, w ith emb o lism (Murch ison),134

cases of (Jones, Gray, Tuckwell), 81cases o f, treated by sulphate o f z inc(Butlin), 81titles o fpapers on, 81

505

Choro id, disease o f, visual sense in

(Forster, Hippel), 364—66tub erc les in the (Frankel) , 91Cho ro iditis, c ircum sc ribed (S ich el), 366syph ilitic , on (Galezowsk i), 368

Chrs chtsch onovitch , on the term inationOf the nerves in the vag ina, 387

Chu

fpder Roy, case Of ab scess o f the liver,

1 0

Church ill, fatty tumour under the tongue,284

Chyluria, filaria in b lo od in (Lew is), 7Cicatrices from burn, treatment Of

(Buck), 331Ciliary muscle, paralysis Of, in diphtheria(Hutch in son), 104C irculation, rapidity Of the, &c ., 8—10Clapham , on sunstroke, 58Clark (Le Gro s), mechanism o f resp iration , 14

Clarke, carc inomatous mass in thorax,111

Clarke (Fa irlie) , case Of c ongenital hypertrophy Of the tongue, 284

un ilateral atro phy Of the tongue, 335Clas sen, cases Of diphtheria, 104Clav ic le, dislo cation Of (see dislo cation),246

necro s is Of, during s carlet fever(Kelly, Nowlan), 61Clay, c ase Of ovario tomy, 305Cleft palate, fo rmation of b one afterOperation fo r (Wh itehead), 233operation for, cases o f (Sm ith,232—33Cleghorn, hydatids of the liver, caus ingab scess, 164

Clem ens, case of vario la , 62

Clément, case of typh o id fever, 53Clements, case Of acute atrophy of theliver, 161Climate, influence Of change of, 14,190—91Climates for consumptives (William s),127Coagulation of the b lo od, on the

(Schm idt, Schifi’er, Bo ll), 7Coal-dust in lungs (Mayet), 123Coats, calcareous degeneration of the

heart, 140

Cobb o ld, on entozoa, 492Co ccius, on testing the tens ion o f the eye,339

Co ckle, case Of aortic aneurism , 201

Cohn , gunsho t wounds of eye, 349—63

refraction Of eyes of ch ildren, 342

Co ld-water treatment Of typh o id (Lis .sauer, S ch o lz, Popper, 54—5 5Co llo id cysts in larynx, 188in lip, 188

INDEX .

Co llo id cysts in thyro id, 188Co lob oma Of the iris , congenital (Ponti),339

Co lotomy for s tricture of rectum, cases o f

(Hulke), 299in intestinal Ob struction (Bryant),294

in recto -ves ical fistula (Bryant), 299Co lour-b l indness, diagno sis o f (Wo inow),340

Co louring matters of the b lo od, 5Coma, dim inished frequency Of pulseb efore death from (Gray), 133

Compress io n (see aneurism), 198, &c .

o f arteries, instrum ent fo r (Stokes) ,209

Condie, c ontagiousness o f phth is is, 128spurious c onsump tion , 125

Consumption (see phth is is), 125Consumptives, c l imates fo r (William s) ,127should they marry ? (W ill iam s, Barnes ,Bennett) 128Contagion, b acteria, &c . , as means o f

(Sanderson, Bas tian, Lo s torfer,36—37by organ ised po ison (Liveing), 37by so lid partic les (Chauveau), 35by unb roken skin surface (Bennett),37list Of authors on subject o f, 37ZOf typhus, direc t (Virchow), 56Convuls io ns after injury to bra in, on

(Callender), 268puerperal, c ases Of , 424w ith lo ss Of speech (Jacks on), 87Copeman, s carlet fever, 487

Copper in ph o sph orus p o isoning, 441po isoning by, on, 443

Cord, sp inal (see sp inal)Co rdier, cases Of diphtheria, 106tub erc le o f cerebellum , 92

Corelys is , on (Wecker), 348Cornea, “

c ells ” o f the, nature of (Geners ich), 33healing ofwounds of (Guterb ock), 34inflammation of the, experiments on,

(Carmalt, S tricker, 33

Corradi , removal Of pharyngeal pro lapsusby the alvanic c autery, 236Co sta (Dag, on irritab le heart, 146Cramp s, o n, during pregnancy and lab our(Mattei), 409Crisp , ab scesses Of the heart, 140aneurism Of coronary artery, 149case o f dilatation of the stomach, 154case of general alopec ia, 184

CriSp , ino culation o f tub erc le, 38Cristo fo ris, cases o f flexion w ithmenorrh oea, 374

Croft, invers ion o f th e b ladder, 275Croton ch loral , o n, 466Croup , developm ent of exudation(Letzericb ), 103nature Of (Hartmann) , 104titles o f papers on, 106—7tracheo tomy in, cases Of, 105

—7Crystals Of the b loo d, on the (Preyer,Brondgeest), 5Cunningham, on cho lera, 479Curran , c ase of sclerias is, 179Cyon , on diab etes in dogs after section o f

ganglia, 20rap idity o f current o f b lood in veins , 9

Cyst o f neck removed (Hardie, Atlee),237Cystic tumours Of breast, o n, reference

(Go odhart) , 234Cys ticerc i o culi , cases of (Hirschb erg), 79Cystine calculus , cases of (Ulzmann),279Czerny, exc ision o f the elbow for anchylo sis , 217

Da Co sta, on irritab le heart, 146on membranous enteritis, 15 5

Dac tylitis syph ilitic a (Taylor), 308Dalm on, detection Of ph o sphorus , 45

Dalton , on the sugar o f the liver, 17Damasch ino , o n infantile paralysis , 96Danet, use Of alcoh o l in pneum onia, 464Danilewsky, quantity Of album ino id compo unds in musc le, 27

Daturine, effects of, on heart (Schm iedeberg), 10

Davis (Dr. Hall), case Of uterine invers ion, 418

Davies (Dr. Herb ert), on the four ori

fices Of the heart, 131

Dawson, invagination Of c o lon , &c ., 432

new c lamp for ovariotomy, 305 , 390:Day (Dr. John) , use o f peroxide of hydrogen pessaries, 461

Decaisne, on an ep idemic Of jaundice,164

m ilk o f women taking insuffic ientfood, 20

on the influence Ofm o ther

’s m ilk , 423

Decap itation as mode 0413

Deglutition, nerves of15

Delafield, p

508 INDEX .

Dufour, case of scleroderma, 179Duhrssen, ab sorption of cheesy products,127

Duncan , caus es Of pro c identia, 383on the curves o f the genital passages ,408

duration o f pregnancy, 401

functions Of th e perinaeum , 384

long delay Of labo ur after dis charge

Of l iquor amnii, 394o n mechan ical dilatation of the cerV1x

uteri, 415mechanism of the expuls ion of the

p lacenta, 407o n the effic ientpowers of parturition,on uterine po lyp i , 380

Dunlop , cases of rOtheln, 62Dupienis, cases Of po st partum haemor

rhage treated b y injections of iodineinto uterus, 420

Dup lay (Dr. S im on), on scapulo ~humeral

periarthritis, 332Dupre, elimination Of alc oho l, 18Duquesnel, on aconitine, 468Dura m ater, tumours Of the (Janeway,Teak le), 93

Durante, experiments o n inflammation,33

Durham, c ompress ion in abdominal sueurism, 205

medullary cancer in axilla, 244on Open ing the larynx fo r removal Ofgrowths , 322

Dust and disease (Tyndal l), 37inhalation of, into lungs (Mayet,Ro ss, Merkel), 123On (Tyndall), 2

Duto it, injection o f ergotin in aneurism ,

199

Duval, on co rneal inflammation , 7on the origin Of pus , 34

Dyce Brown (see Brown)Dysentery, l is t of papers on, 159Dysmenorrhoea, case Of inflammato ry

373cases Of, with flexion, &c ., 374dilatation o f cervix in treatment Of

(Edis), 375essential cause of (Barnes), 374interm enstrual , O1I (Priestley), 374

Dyspep sia for starchy food in infancy,429

Dyspnoea, no cturnal, in disease Of theheart (Habershon), 133

Dysto c ia by the ch ild, 411—12by the mother, 410

—11E ar, removal o f foreign bodies from ex

ternal (Gruber), 335

E b ell, vaginal s teno s is, 386E bstein, secretion Of glands Of

16

E cchym o ses after suffo cation, on

komsky), 460E ch ino c o c c i (s ee hydatids ), 163Ecraseur, a rectilinear (No tt), 244E czema , papers on, 186

E des , tum ours in c onnection withvous system , 93

E dis , ab s ces s Of the ovary, 388treatment o f dysmeno rrhoea, 374

E lam , idiopath ic c erebritis , 91E lbow , d is lo c ation Of (s ee the)

exc is ion o f the

E lectric exc itatio n Of musc le, 31E lectric ity, use o f, in m idw ifery, 409E lephantias is, papers on, 187

Arabum , patho logy and cases Of,181—82Graecorum , cas es o f (Anderson), 182

E mac iation in typho id (Al lbutt), 5 2Emb o l ism, c ases o f, 134—36gangrene o f feet from , 2 13

intra -cranial, c ases o f, and titles Of

papers o n, 91- 93

titles o f papers on , 136

w ith heart disease, cas e o f (S imon),141

Emetine, detection Of (Pander), 45 5Emmert, on exOphtb almic goitre, 77Emmet, septicaem ia after removal ofuterine fibro id, 379

Emphysema, changes in vessels in (Isaakson), 116during lab our, cases of, 418—19instrument fo r treatment Of (Berkart),116

titles Of papers o n , 116—17E mpyema (see a ls o pleurisy), 113

titles o f papers on, 115

Encephalitis, diifnse, in new-born children (Jastrowitz), 91

Enchondroma Of the ribs (Billroth, Men

zel), 241o f phalanx o f thumb , 218

E ndo carditis , titles Of papers on, 142

in pig, w ith arthritis (Bo th), 74ulcerative, case o f (Heiberg), 140

E ngelmann, on innervation o f the con

tractile gland-c el ls Of the frog, 24o n wrinkles in nerves, 21

E nglisch , on hernia Of the ovary, 291E nteric fever (see typh o id), 5 2—5 5E nteritis, membranous, o n (Da Costa,Wh itehead), 15 5—56

E nto zo a, relation of, to pub lic health,492

E ph idro sis unilateralis, cases of, 183Ep idermic grafting, on, 335

INDEX .

Ep ididym itis, treatment of, by ice (Borgioni), 282

Ep ilep sy after injuries to the head (Langenb eck ), 83brom ide Of po tass ium in (Vance,Lutz), 83from necro s is Of femu r

(Martin), 83in guinea p igs (Brown Sequard,Westphal) , 82production Of, in guinea -

p igs (West

phal), 23titles o f papers on, 83

Ep istaxis, treatment o f (Kuchenmeister),334

Epithelioma Of the tongue, rem oval Of,w ith galvanic w ire (Go zzini, Pucc ioni) ,283

s imulating bub o (Geb er), 273Ep ithelium , development of c iliated (Letzerich) , 103

E rgo t, action Of, o n the foetus, 421

use Of, in ab o rtio n, o n (Ba ssett), 402E go tin, injection Of, in aneurism (Duto it),199

in treatment Of varix (Vogt), 211E rich sen, am putation at the knee-jo int,212—13dislo cation at the knee, 254dislo cation o f wrist, 248hernio tomy in infant, 288Ob turato r hernia, 291wrist-drop after injury to nerve infracture, 256

(Petersb urg), on cho lera, 481E rismann, refrac tion Of eyes o f ch ildren,E rys ipelas , bacteria in b lo od in (Nepveu),37laryngeal Ob struction wi th (Russell),101

sub cutaneous antiseptic injections in(W ilde), 318traumatic , on (W ilde), 318

E rythem a exsudativum multiforme, on

(L ipp), 174m arg inatum , paras ite in (Fox), 184papers on, 186

p aras itic (Kohn), 185so lare, c ase Of (Wilso n), 175

E smarch , ice in acute rheumatism , 74E sp ine (M. d

’

) on puerperal septicaem ia,422

E ther, death from the adm in istration Of,193—on the adm inistration of (Haward), 193E ulenburg, c ases Ofmuscular atro phy , 70

on cerebro -sp inal m en ingitis, 43toxic o logical effects Of tobacc o , 450on yellow fever, 46

Evans, hydat id cyst Of cerebellum, 93

509

E vans, on th oracentes is , 113E wens, case Of exc is ion o f th e sho ulder,215

E xanthemata, the acute, 58, &c .

E xc is ion o f the ankle (Gant, Watson,

Maunder, Canton ) , 2 26o f the ankle, and removal o f the tarsalb ones (Swa in), 226Of th e astragalus, cases Of (Gant, Hanc o ck, 226

Of the astragalus, malleo li, &c . (Wat‘

son) , 226Of bo th astragal i in case of talipes(Lund), 226Of the breast, 233 - 34

Of the breast, m ode Of performing(Bell), 234Of b oth elbows (Fo rster), 218of the elbow in anchylo s is (Annandale) , 216o f elbow for anchylo s is after dislo cation Of radius (Watson), 217Of the elbow for anchylo s is (Czerny) ,217Of elbow for compound dislo cation(Malins), 218Of elb ow for Old dislo cation (Marshall) ,218

of th e elbow , on (Gant), 215Of the elbow, primary, on (Maunder),216

of end o f humerus fo r anchylo sis o felbow (Watson), 218o fthe hip , amputation after (Jacks on),221

o f the hip-jo int, cases of, 220—21

Of the hip~jOint, o n (Gant), 218—20

of the h ip , spec imen from (Annan f

dale), 220Of the knee, on (Gant), 221—22o f knee, c ases of , 222—23of knee, sources of fai lure after

(Treves), 221Of lower jaw, m ode Of performmg(Watson, Lizars), 228- 29

o f lower jaw, through the m outh

(Maunder), 235Of o s c alc is (Gant, 226—27Of phalanx Of thumb for enchondroma

(Bell), 218o f sh oulder and elb ow in sam e arm

(MacCo rm ac) , 213Of the sh oulder, c ases (E we11s) , 215of the sh oulder, on (Gant), 2 15Of the superio r m axilla , 229 - 30

Of the tarso -metatarsal jOints (Ho lmes),227 -28Of the tro ch anter m aj or (Gant), 219Of wedge o f b one at knee for anchy

a

lo sie(Morton,Adam s,Watson), 223—25

5 10 INDEX .

“

E xc is ion Of the wrist, cases of, 218E xerc ise, effec ts Of, on the b odily temperature (Allbutt, 15

E xophthalm ic go itre, cases of, and titlesOf papers on , 7 7

E xo sto s is from first rib , rem oval of (Birkett), 240E xtender, sp iral spring (Ho lthouse) , 25 5Eye, gunsh o t wounds Of (Cohn), 349—63instruments, new, 363—64

syph ilitic affections of the interio r Ofthe (Galezowski), 368

Eyeb all, c o ntus ion o f, case o f, 361

enuc leation o f, in sympathetic Oph

thalmia (Cohn, Moo ren), 35 5—60on testing the tens ion Of the (Co ccius),339on tens ion Of the (Monnik), 338

Eyelids, suture o f the (Verneuil), 349Eyes, co lour o f, in the newly bo rn, 426

Fac ial paralysis after chorea (Buzzard),81

Faeces o f sheep in fo ot-and-mouth disease

(Hallier), 79Fagge, c ase of intestinal Ob struction, 293murmurs attendant on m itra l contraetion, 140p o st

-m ortem changes in scleroderma,

178Falck, on urea, 172Farquharson, cases of pneumoma , 118

o n revacc inatio n, 431Fasbender, cases Of vers ion , 415

Fat, storing up o f, in fat-cells (Hoifmann),32

Fatty mas ses in a ranula (Tay), 284tumour under the tongue (Church ill),284

Fauvel , o n cho lera, 49Favus, frequency Of, in S co tland, 185Fayrer, radical cure o f inguinal hernia,288

o n snake po isons, 45 3Febris lymphatica (Harley), 61Femur, d is lo catio n Of (see dislo cation), 253

neck Of, sub cutaneous divis ion Of

(Adams), 234necro s is Of, produc ing epi

lepsy (Mar

tin), 83Ferb er, case Of rheumatism , 73

on hay fever, 43Ferguson, c ase Of hysteria, 80Fergusson (Sir exc is ion Of superiorm axilla, 229ligature Of the sub clavian artery, 201

Ferment, acting on starch, found in

many parts (Lep ine), 16Ferrier, fung i in b lood, 36

on mo lluscum contagiosum, 182

Fever, action o f alcoho l in, 464dengue, titles of papers o n, 43exanthematic (see measles , 58,&c .

fo llowing surgical operations ,(Wells), 317hay (see hay fever), 43interm ittent, aphas ia in (Bo is seau), 45interm ittent, intra-uterine (Bazin), 45interm ittent, relation o f, to relaps ing(Senator), 5 7interm ittent, titles o f papers on, 45puerperal , on, 398, 421

relap s ing (s ee a ls o relap s ing),relaps ing, case at G lasgow (Tennent),5 7relaps ing, ep idem ic s of, 486relaps ing, incub ation o f (Murch ison),41

relaps ing, in London , 5 8

relaps ing, outbreak o f, at Leeds (Ro binso n), 5 7relap s ing, pos t

-febrile Ophthalmiaafter (Charter-is), 5 7relaps ing, relation o f, to interm ittent(Senato r) , 57traumatic , from gunshot wounds

(Hueter), 315traumatic , on (Billroth), 311typho id (see typho id), 5 2—5 5typho id, tub erculo s is after (BirchHirs ch feld) , 39typhus (see typhus), 56urethral, fata l, after catheterism

(Banks), 271o n war typhus (Vircho w), 56yellow, o n (Munro , Sullivan, Hiron,E ulenb erg , 45—47yellow, titles o f papers on, 47

Fevers , incuba tion o f (Murch ison), 41list o f authors on , 41

swelled leg o f (Begb ie), 41Fick , effects o f heat o n the heart, 9

effects o f heating and co o l ing the

b lo od pas s ing to the nerve-centres, 22

on the peptones , 16

Fieber, sp inal hem ip legia, 84Filaria in the b lo od in chyluria (Lewis), 7Finney , c irrho sis o f kidneys, 170Firmy, antagonism b etween atrop ine andm orph ine, 439

Fistula, recto -ves ical, co lo tomy in (Bryant), 299ves ico -vaginal , on (Bell), 282uretero -uterine, cases o f, 417

Fitzmaurice, on pneumonia , 118Fleischman, ca se o f cerebral tuberc le, 92develo pm ent of teeth in rickets, 76m ortal ity o f scar let fever, 5 9symptoms of rotheln, 62

5 12 INDEX .

Gangrene, ho sp ital (Heiberg), 318of feet from emb o lism, amputation in(Gant), 213o f the lung, 122—23seni le, amputation in (L ister, Mor

gan), 213Gant, amputation in gangrene from

emb o lism , 213

exc is ion o f the ankle, 225on exc is ion o f the astragalus, 226do ., o f the elbow , 215

do ., o f h ip-j o int, 218

do ., of the knee-j o int, 221do . , o f the sh oulder, 215do ., o f the o s calc is , 227

Garden, o rch itis after lithotomy, 274Garrod, on a c ardio -sphygmograph , 9

on lead po iso ning, 99Gases, exchange o f, in the p lacenta , im itatien of (Bern stein), 14

Gastric juice, effect o f, o n uterine c ancer,382

Gastro tomy for intestinal ob struction,296—98in extra -uterine foetation, 404

Gatzuck , effec t o f, venesection on arte

rial current, 9Gay (C. C . ligature o f sub clavian intraumatic axillary aneurism , 202

Gay (John), case o faxillo -sub c lavian aneurism , 201

cases o f exc is ion of the hip-jo int,

220

ligature o f sub c lavian artery, 202

Gay. on h isto logy o f prurigo , 178patho logy o f the sweat-glands in

eleph antias is , 181Gayet, case of cystic myoma of uterus,881

Geb er, case o f ep itheliom a s imulatingb ubo , 273

Geltowsky, ac tion o f quinine on b loodc orpus c les , 7

Gemma, o n pellagra, 67—68Genersich , ab so rptio n o f lymph by tendo ns, &c ., 3

o n the cells o f the co rnea, 33Genital passages, on the curves o f the

(Duncan) , 408Gerhardt, c ases o f pap illoma , 181

Germ s, ac tion of sulphurous acid o n,

492

o n development of (Bastian, Sanderson , 2

o n detection of b lo od-sta ins, 45Gescheidlen, distribution of urea in the

b o dy, 19

Ge

iisn

g, on detection of b lood - stains ,

Gibb ons, case of Caesarean section, 412

G iese, m ode of origin of sou

129

Giles, o n gonorrh oea and pwomen, 166

G illesp ie, c ases o f exc is ion o f the

223

dry dress ings to wounds , 195Gimb ert, b rom ide o f p otass ium in

vom iting o f pregnancy, 400

G ier, o n arsen iate o f quin ine, 463G iovanni , po s ition o f the h eart, 132

Gland-cells, innervation o f contractile,frog (E ngelmann) , 24

Glands, authors on anatomy o f, 20

lac hrym al innervation of25

mesenteric , anatomy o f (Pepsalivary, affections o f the, liston , 152

- o f the stomach, secretion o f the

stein, 16

term ination of nerves in (Pfiu24

uterine, ep ithelium o f (Lott), 30G laucoma, value o f iridec tomy inlius), 347Glo sso -

pharyngea l nerve, case o f po f (Taylor), 91

Glover, c ase o f pericarditis, 137G luge, case o f typho id , 5 3

Glycogen in b lo od-c orpus c les, wh ileb ile (Ho ppe-Seyler), 8

Glycerine lymph , o n, 431Go itre, ex0phthalmic , c ases o f, and titles

o f papers o n, 77Go ld, chlo ride o f, action o f, 462

ch loride o f, in nervous diseases (Martin),402

Go ltz, on ab so rption o f po isons , 433influenc e of nerve centres on abso rption, 4

Gombault, case of progress ive mus cularatrophy, 71

Gono rrhoea and peritonitis in women

(Giles), 166Go norrheeal rheumatism (Bond), 282Go odell, on the m anagement o f the pe

'

rinaeum during labo ur, 409Go odfellow, case o f disease o f the heart,139

Go odhart, ino culation of tubercle, 38Go odridge, case o f acute atrophy o f the

liver, 161Go sselin, subastragalo id dislocation o f the

feet, 254

Gott exc is ion o f superior maxilla,230

Gout t et, on actio n o f digita lis, 470Gout, co nnection o f, w ith hay fever(Guéneau de Mussy), 43

INDEX.

Gozzini, removal of pharyngeal po lypusby galvanic cautery, 236removal o f the to ngue w ith the gal

vanic w ire, 283Grafting , ep iderm ic, o n, 335

skin , o n, 335

G ray (St . Clair), antagonism of nitrite o famyl and s trychn ine, 440(of Oxford), cases o f chorea, 81

Gray, fall in frequency o f pulse b eforedeath from c oma, 133

Gregory , on weight o f infants , 425Green, case of disturbed innervation of

the heart, 147case o f interstitial hepatitis , 162interstitial pneum on ia, 120

Greene, rem oval of b ronch o cele, 236Gréhant, on action of aconitine, 468Greenh ow, case of lo como tor ataxy, 98

paralys is in diphtheria, 105Greyness o f ha ir, prem ature, on (Pincus ,Berger), 184Gro ss on ulceration of the jugularveins , 326Ground water, influence of, on spread of

cho lera, 477Gruber, rem oval of foreign bodies fromexternal c ar, 335

Grun, on typhus , 485Gub ler, nervine symptom s of smallpox,63

Guénio t, on ab sorption of uterine fibro ids ,880

on frac tures of the th igh in the newlyb orn, 427haem atoma in typho id, 5 3on urinary umb ilica l fistulas , 427c ongen ital invagination of the rectum,

432

Guilland, c ase of ino culation o f smallpox431

Guinea-p igs, ep ilepsy in (Brown-Sequard,Westphal), 82

Gull, on Bright’s disease, 168Gunning, on detection o f b lo od-stains,459

Gunsho t, treph in ing for (Halstead, Howard), 265

Gunsh o t injuries of b one (Mac Corm ac),264

injuries, m ortality after, c omparedw ith c ivi l practice (Vo lkmann) , 260injuries to the b rain, cases of (Cohn),352

wound o f chest, fourfo ld, recovery after(Lorinser), 264wound o f neck, retention of ball(Baumes) , 264—2

wounds, experience in (Mac Cormac),63

5 13

Gun shot wounds o f eye (Co hn) , 349—363—w ounds o f lower extrem ity (Mac

Cormac) , 266wounds, Operations not adapted for

(Mo ore), 263wounds, surgery o f arteries in (Verneuil), 263wounds , traumatic fever from (Hueter) ,315

Gu

s

s

ge

7

mw, anaem ia during pregnancy,

on urea in liquor amni i, 17Guterb o ck, em physem a in diphtheria,105

healing o f wounds of the cornea, 34

Hab ersh on, cases of disease o f the stomach ,154

no cturnal dyspnoea, 133peritoneal adhes ions giving rise to

pain, 166

Haematidro s is, c ase o f (W ilks), 183Haemato cele, pelvic , on (Meadows , Beck),391

Haem atoma in case of scarlet fever (Hub er), 60in typh o id (Guéniot), 5 3

Haematometra, 369—70Haemato zo on , a peculiar c iliated (BoydMo ss), 7

Haem aturia, paroxysmal, on (Pavy), 170titles o f papers , o n, 170

Haem oglob in c rystals, &c . (Preyer) , 5Haem optys is, experim ents on , as cause o f

phthysis (Sommerbro dt), 126in phth is is, propo rtion of (William s),127

Haem orrhage from kidneys in infants, 432m eningeal, titles of p apers o n, 89—90recurrent, after amputation, 211secondary, after del ivery, 424supplem entary to menstruation, 373transfus ion fo r, 419

Hafiz, properties o f musc le, 27Hainwo rth , case o f po isoning by carb o lic

ac id , 446

Hair, lo ss o f, over the wh o le b ody (Crisp),184

papers on diseases o f, 187prem ature greyness of (Berger, Pincus), 184structure o f, in its m edico -legal as

peets, 459

Halb ertsm a, external exam ination of

uterus in lab our, 415Hallier, exam ination o f faeces of sheep in

fo ot-and-mouth disease, 79Hallopeau , on chron ic myelitis, 93Halstead, treph ining for gunsho t, 265Hammarsten, ab sorption of lymph, 4

33

5 14 iNDEi .

Ham ilton, c ase o f tum our of the lowerjaw, 229

Hamm ond o n aphas ia , 86o n m o nob rom ide o f c am ph or, 469

Hanc o ck , exc is ion o f the astragalus , -226

on exc is ion o f the h ip-j o int, 220

exc is ion o f wrist, 218Hanson, regeneration of ep ithelium of

c o rnea, 33

Hardie, rem ova l o f c ongenital cystictum our o f neck, 237sp ontaneous separation o f uterine

fib roid, 380Harley (J o n sc arlet fever, &c ., 61

Harri s, cases o f Caesarean section, 412o n Caesarean sectio n , 306

o n fo rm s o f pelvic disto rtion, 410Hart case of hydro cele o f the roundligam ent, 391

Hartmann , o n c roup and diphtheria, 104Hasse, co urse o f b lo od in spleen, 19

B attute, ca se of eleph antias is , 181Haughto n , m echanic s o f musc le, 30Haward (Mr. o n ether and ch lo rofo rm , 193

Hay remo val o f inverted uterus w ithin tramural fibro id, 377

Hayden, diaphragmatic pleurisy, 114Hayem , case o f pneum o nia, 119

on s curvy , 7 5

Hay fever, relation of, to gout (Guéneaude Mussy), 43quinine in (Ferner), 43sym ptom s o f (Waters), 43titles o f papers o n, 43

Hayes , m ethod o f securing vessels o f

pedic le in o vario tomy, 390Haynes, dislo catio n o f b o th ends o f

c lavic le, 247Head, gunsh o t injuries to , 265injury to , cases o f, 266—68injuries to th e, o n artific ial resp iration in (Sch iff), 14injury to the, emphysema and ec chym o s is o f lungs ih—experiments (BrownSequard) , 108

Health , pub lic, report on (Stevenson),472reso rts, on, 190

—91Hearing, action o f the tens or tympani on(S chapringer) , 2 5

Heart, ab scesses in the (Crisp), 139action o f c amph or on the, 46 9

aneurism of m itral value o f (S imon),141

aneurism o f the (Murch is on, Townsend), 139c alcareous degeneration o f the (Co ats),140

cancer of the (Payne), 139

Heart, case o f disease o f tricusp ido f (Wh ipham), 141case of disease o f (Sm ith), 138c irculatio n in, w ith inspi

(Quincke, Pfeiffer), 13c ongen ital m alfo rmation o f the

o f, 147—48do . , list of papers o n, 148—49dilatation o f the, on (Thompso n) , 138disease o f, case o f (Go odfellow), 139disease, c ases o f, w ith embo lism , 134—36— disease c omplicated w ith pregnancy

(Sp iegelberg), 398disease of, during pregnancy, causatio n o f (Leb ert), 397disease o f the walls of the (Quain),137disease, on preventio n o f (Stone) , 132disease, titles o f papers on, 134, 142

43

effects o f heat on the action o f the

(Ceradini, Brunto n, Fick) , 9effec ts o f strain o n th e (All butt), 132effects o f temperature on the (Brunto n), 133effects of the, on resp iration (Lando is,Ccradini) , 13fibrous tum our o f the 138

hypertrophy, &c . , of the, on (Fo therg ill), 138irritab le, o n (Co sta), 146murmurs in diseases o f, on, 129—34do ., titles o f papers on, 134nervous palp itation of the (Mazza) ,147neuro sis o f the (Nunneley, Mo inet,

145—47no cturnal dyspnoea in disease o f the,133

o rifices o f the, o n (Davies) , 131o rigin o f firs t sound o f the (Giese),129

palp itation o f the, on (Nunneley), 145po s itio n o f the (Giovanni), 131presys to l ic murmur in disease o f, on

(Fagge), 140rupture o f the, c ases o f, 143—45sounds of, audib le after cessation of

resp iration, 141sounds o f, intens ification of the

(Po ore), 130so unds of the, titles o f papers o n,

134

valvular disease o f, progno s is in (Peac o ck) , 139

Heart’s action, effects o f resp iration on

(Hering), 10Heat, effec ts o f, o n action o f the heart

(Ceradini, Brunton, Fick), 9

5 16

Ho llis, case of s imultaneous lead and

m ercurial p o ison ing, 99Ho lmes (Tim othy), exc is ion of the tarso

m etatarsal j o ints , 227—28on exc is ion o f the knee-jo int, 222flexio n of leg in pop liteal aneurism , 209

o n surgical treatm ent of aneurism , 198

treatment of suppurating ovariancysts , 302

Ho lthouse, removal of trach eotomy tub e,321

sp iral spring extender, 25 5

Ho ner on ch o lera, 481Hoppe

-Seyler, glycogen in b lo od, 8o n d is infection, 492

Heseb eck, c ase o f Caesarean section, 413

Ho sp ital gangrene, on (Heiberg, Jon es)18—19

Howard, treph ining fo r gunshot, 265Hub er, haematom a in s carlet fever, 60Huchard, c ause o f death in sm allpox, 63Hueb el, active p rinc iples o f tob acco

smoke, 451Hueter, traumatic fever from gunsh ot

wounds , 315

Hughes , case o f rupture o f the heart, 145

Hulke, c ases o f c o lo tomy for stricture ofrectum , 299

c ase o f c left palate, 233case o f gastrotomy fo r intestinal obstruct ion , 297cas e o f ligature o f radial, 210case o f stri cture o f urethra, 272

Hum erus, dislo cation o f (see dislo cation),247

Humphry, on myo logy, 31Husemann , on chlora l hydrate, 465p o isonous actio n o f fungi, 45 3

Huss, pain in p leurisy, 112Hutc h inson (Mr. Jo nathan) , atrophy o f

triceps after frac ture o f the Olecranon,2 57c ase o f c erebral tum our, 92ease o f incarcerated s cro tal hernia, 289c ases o f vacc ine-syph ilis , 306chronic rheumatic arthritis, 326inc ontinence as a symptom of reten

tion o f urine, 273on o rch itis from irritatio n of the pro s

tatic urethra, 273paralys is o f c iliary mus c le in diph

theria , 104on perio stitis o f temporal b one, 333xanthelasma palpebrarum , 183

Hutton , prediction o f sex of ch ild by auscultation , 396

Hydro cyanic ac id, detection o f (Almen,Preyer), 454

Hydatids in the brain, c ases (Reeb), 78in the lung, case (Zuber), 79

INDEX .

Ichthyo sis, papers on, 186Icterus neonato rum , 432

Ic terus, o n , 164

Iliac artery, c ommon, l igature of the, forhaemo rrhage (Baker), 207external ligature o f the, c ases of,207—8

Ihlder, nerves o f the tongue in b irds , 25Impetigo , papers o n , 186

Incubation o f fevers (Murch ison) , 41Induratio n o f lungs, b rown (Delafield,Rindfleisch) , 121

Infantile paralys is, c ases o f, nature o f,&c . (Damas ch ino , Roger, Rinecker,Ro senthal), 96—97para lys is, titles o f papers o n, 97Sp inal para lys is (Charc o t), 95

Infants , h aemo rrhage from the kidneysin, 432

o n feeding o f, 430

o n still-bo rn , 425

weight o f, 425

Infection from po ison o f animal s, list o fauth ors o n, 42

list of autho rs o n subject of, 37m eans o f (see a ls o c ontagio n), 3 5—37use of resp irato r to prevent (Tyndall),37

Inflammation, condition of the walls of

the vessels in (Durante), 33

Hydatids of cerebellum , cases o f, 93of the liver, cases o f, 163of the lungs (Leb ert, Zub er, Bird),124—25

Hydro c ele o f the round ligament, case of

(Hart), 391Hydro cephalus, cases o f, and titles o f

papers o n, 89

chronic , on, 429Hydro ch loric ac id, cases o f po isoning by,442

Hydro cyan ic ac id, action o f (Preyer) , 446act ion o f (Am ory), 448

Hydrogen, peroxide of, use in pessaries(Day), 461

Hydro ph ob ia, h isto logy o fnervous centresin (Al lbutt) , 42list o f authors on, 42—43patho logy of (Rudnew), 42

Hymen, im perfo rate (Barto n) , 282Hyperaesthesia, titles o f papers o n , 88

Hypermetrop ia , frequency of, 342Hypertrophy, c ongenital, c ase o f, 428

Hysteria , ca se of analgesia w ith (Ro senthal), 80c ontrac tion o f limb s in (Charcot), 79on c as es o f suppo sed (Fuller) , 80titles o f papers o n, 80

trance in (Jam ieso n), 80

INDEX.

Inflammation in the cornea, experimentso n (Heiberg, Hansen, Carmalt, 33

l is t o f authors on , 34

pers istent, treatment of (Marshall),334

the s tate of the walls o f the Vesselsin (Durante), 33

Infusio ns, development o f b acteria in

(Sanderson, Bastian), 36Inglis, case of Caesarean sectio n, 412Injec tion in tumours , (Heine), 244Innervatio n o f co ntractile gland-cells of

frog (E ngelmann) , 24Ino culab ility o f tub ercle (various), 38- 39

Ino culation of small -pox, case of, 431

Innom inate, c ompression and ligature of(Bickersteth ), 201

Inso latio , on (Th in, Macdonald, Clapham), 58

Interm ittent (see fever), 45Intestina l ob s truction , c ases o f, 293—99

ob struction, formation of artific ialanus (Me Carthy) , 296o b struction from b ands o f lymph ,

cases of, 298

o b struction from c ongenital c onstriction (Southey) , 295ob struction from a kno t (Taylo r), 295o b struction from peritonitis, case o f

(Buchanan), 296ob structio n , l ist o f papers on and cases

ofi 158 —59ob structio n , on lumbar c o lo tomy in

(Bryant) , 294o b struction w ithout s ickness (Bell,Cro o m), 295

Intestine , changes in, in typh o id (Hesch l,Murch ison, Ma clagan), 52puncture of, 297

puncture o f, in hern ia (Bryant), 289syph ilitic disease o f small (Oser), 65wound of, case of, 299

wo und of, during ovario tomy (Heath),305

Intestines, affections of the, list o f paperso n, 157

Intussusception (see invagination), 432lis t of c ases o f, &c ., 158

Invagination, congenital , o f the rectum ,

432

o f the c o lon, &c ., 432

Iodine as injection in chronic metritis ,392

caus ing pemph igus (Bum stead), 176Iridectomy, value o f, in glaucoma (Quaglin o ), 347

Iris, c ongen ital c o lob oma o f the, 339

Iro n, ch lo ride o f, action o f, 462

perch loride o f, as an injection in

chronic metritis, 392

5 17

Isaakson, on emphysema, 116Isambert, pharyngo

-scro fulous angina,151

Itch , treatment of (Monti, Weinberg),185

Jackquet, cysts o f the p lacenta, 394Jackson (J. Hugh lings), c onvuls ions andlo ss o f speech , 87power o f s ing ing rema ining in two

aphas ic b oys, 88tuberc le o f th e cereb ellum , 92

Jackson (T . Carr), amputation after ex

c ision of th e hip, 221

exc ision of the a stragalus, 226Jac ob i, on c ase of foetal asymmetry, 427Jac o b son, on co inc idence o f murmursw ith period o f heart

’s action, 129

Jalland, c ase o f vaginal thromb us, 419Jam eson, case o f ab s cess o f the liver, 159Jam ieson, case o f p opliteal aneurism ,

209

c ase o f tranc e, 80

c ase o f vaginal rupture, 417Janeway, tumo urs o f dura mater, 93

Jarisch , c ompo s itio n o f the b lo od, 6Jastrowitz , hereditary character of ner

vous diseases, 91Jaundice, authors on, &c ., 164

in new -b orn ch ildren, 432Jaw, lower, anchylo s is of the, operatio nfo r (Bo ttini, Maas), 230lower, exc is ion of, &c . , 228—29lower, myelo id tumour o f (Maunder),235

lower, removal o f, through the m outh

(Maunder), 235upper, exc is ion o f the 229—30upper, resection o f, fo r rem oval o f

naso -

pharyngeal tum ours (Burns), 235Jefl'freys, case o f p o isoning by carb o licac id, 446Jeuks, c ase o f placenta suc centuriata,424

Jess0p, use o f pneum atic resp irator, 232Jo fi'

roy, case o f tetanus, 98

changes in paralys is agitans, 97Johnson extra -uterine foetation,404

Johnson (Dr. diagno sis o f aorticaneurism w ith th e laryngo sc o pe, 149on Bright’s disease, 167—68on laryngeal spasm , 102

o n scarlet fever, 487Johnson (Metcalfe), ph o sphate o f lime inthe vom iting o f pregnancy, 400

on transmutation o f fo rm in certainproto zoa, 3Jo int disease, necrosis in (Treves), 325

5 18 INDEX .

Jo int, knee, lo o se cartilages in , removalo f (Square), 326Jo ints , am putation through (see ampu

tatio n)disease of, authors on, 326disease o f , from continued rest,

(Menzel), 325exc is ion o f (see exc is io ns) , 213Jones (Handfield), cases of acute rh eu

m atism , 74

cases o f chorea, 81

o n case of p leurisy, 112Jones on h o sp ita l gangrene, 319Jones (Sydney), cases o f exc is ion o f the

knee, 223exc is ion o f wrist, 218

Jo nes (T alfourd) , o n use of n itrite o f

amyl, 467Jordan (Furneaux), new method o f re

m oving the to ngue, 283Joulin, on th e lam inar membrane o f the

human placenta , 394Jugular veins , ul ceratio n of the, o n

(Gro ss) , 326Julian, on cap illary bro nch itis , 116Junker, on the us e of the trachea l tamp on ,

319

Jurasz , action o f b ile on the b lo od-c or

pusc les , 6

Kaltenb ach , album inuria during pregnancy, 396Kehrer, jaundice in new-born ch ildren,432

m orpho logy of m ilk cas ein, 423

Keith , cases o f ovario tomy, 302on ovariotomy, 389Kelly, case o f c o ngen ital malformation of

th e heart, 148

case o f scarlet fever, 61Kelo id, o n (Kohn, Fo x) , 180Kennedy, on phth is is, 126Keratitis, experim ents on (Carm al t,

Stricker, 33

Kerner, action o f quinine on b lo od-corpusc les, 7Kersey, outb reak o f diphtheria , 105Kidd, decap itatio n as mode of delivery,413

o n uterine fibro ids, 379Kidney, amount o f uric ac id excreted bythe (Saw icki), 30atroph ied, uraem ia from (Murch ison),169—1

l

é

right’

s disease o f, caus es o f (Roberts),8

Bright’s disease o f, diagno sis, &c . , o f

(Johnson), 167disease of, dropsy in (Wood),

Kidney, Brigh t’s d isease o f the, titles o fpapers o n, 17OBrigh t’ s disease o f, w ith contracted

kidney (Gull and Sutto n), 168c irrh o s is o f th e (Finney), 170d isease of, ending in apoplexy, 169extreme, granular degeneration o f,w itho ut c ard iac affection (Moxo n), 169hydatids in the (Shepherd) , 171hypertrophy of , on (Ro senstein , Perl),171

syph ilitic disease of (Bradley), 168titles o f pap ers on affectio ns o f th e,171Kidneys, h aem orrhage from the, in

infants, 432on fo rmation o f urea by the (Ro senstein) , 19King removal of tumour o f palate,238

King (Pro fi), relaxation of pelvic art icalations during pregnancy, 407King (Surgeon), o n c o ld foo d for infants,430

Kittel on trich ino sis, 78Klein , development o f earliest c orpusclesand b lo od-vessels, 7distributio n o f nerves in memb rana

n ictitans , 24o n serous membranes, 4

Knee, amputation at the (see amputatio n)anchylo s is at, exc is io n of wedge o f

b one in, 223—25anchylo sis at the, sub cutaneous osteo

tomy in (L ittle) , 225dislo catio n at the, 2 54

exc is ion of the (see a ls o exc is ion)Kno ll, p seudo -hypertroph ic para lys is , 71Kbbner, reinfectio n o f c onstitutionalsyph ilis, 306Ko cher, o n traumatic aneurism o f the

vertebral artery, 202Koh ler, on anaesthetic s, 465Ko hn, on kelo id, 180

o n paras itic erythema, &c . , 185

Konrad , etio logy o f pro lap se o f femalegenitalia, 383Kerner, o n tuberc le, &c ., 126

o n tuberculo s is, 108Ko tsono pulo s, o n ep idem ic o f c erebro

sp inal m eningitis , 44Kowalewsky, o n arterial current, and

arterial pressure, 9Kra ft-Eb ing, paralys is after diphtheria,105

suppuration in musc les, after typho id,5 3

Kratschmer, on diab etes , 73Kriinlein, on open treatment o f wounds ,195

520 INDEX .

L ife, phenomena of, influence of baro

m etric pressure on (Bert), 13L igature (see artery)antiseptic catgut, on, 195antiseptic, of innominate (Bicker

steth), 201c atgut, haemorrhage after use o f

(Ho lden), 209o f c ommon carotid in aortic aneurism(Heath), 201o f common carotid artery for aneu

rism (Lane, Gamgee), 200of the common iliac artery (Baker),207

of the external artery, c ases of

207—8L igh t, v io let, influence o f, on growth

(Pleasanton) , 18L ime, effects of ab sence of, from food

(Weiske), 29

pho sphate o f, in vom iting of pregnancy (Johnson), 400L ing , absence o f ovary, &c ., 371

injury to pregnant uterus , 400L ipp, on erythema, 174L issauer, treatment o f typho id, 54L ister, on antiseptic surgery, 194

am putation in senile gangrene, 213case of, amputatio n o fthehip -jo int, 211cases of popliteal aneurism , 209

catgut sutures to tendinous openingsin hernia, 289exc is ion o f wris t, 218o peration forununited fracture o fnecko f femur, 259

removal o f lo o se cartilages from kneej o int, 326treatment o f c icatri ces, 332

L itho tomy, cases o f, &c . , 2 77haem orrhage after (Square, Tay), 277in female, 278—79o rch itis after (Hutch inson , Garden),273- 74

rectal (Sch affer), 278rem oval o f p iece o f b one from the

b ladder (Thompson), 277L itho trity, c ase o f, w ith atony o f the

b ladder (Matiejowsky) , 276Little (Dr. antagonism between

b ellado nna and Op ium , 439

L ittle (W. sub cutaneous o steo tomyat knee, 225L ittleton, on overlaying, 427Liveing, cases of m o lluscum contagio

sum , 183

po is on o f co ntagious diseases, 37L iver, ab scess o f the, cases o f, 159—60—6

acute atrophy o f the, cases o f, 1601

do ., list of papers on, 161

L iver, cancer of the, cases o f, 163c irrho s is of the, cases of, 161—62do ., list of papers on, 162

depo s its in, in syph ilis, on (Simon),66

hydatids o f the, c ases of, 163—64do ., list o f papers o n , 164

l ist o f papers on various affect ions o fthe, 165

s ize o f, in children (Steffen), 165sugar o f, on (Dalto n), 17

Lizars, exc is ion o f the lower jaw , 229

Lo como to r ataxy, case of (Greenh ow,

Cayley), 98titles o f papers on, 98

Lohmeyer, use o f pneumatic asp irato r,232

Long , calculus in female, 278Lorain , case o f woman w ith four breas ts ,371

Lorinser, fourfo ld gunsho t injury to

chest, rec overy, 264Lo sto rfer, diagno s is of syph ilis by them icro sc ope, 64fung i in b lo od, 36fungi in human b lood , 7Lott, ep ithelium of uterine glands , 20Lowe, case o f rupture of the heart, 145

Opening the stomach for cancer, 299

Lubanski, ulcerative angina , 151Lucas , a new plan o f us ing acupressure,198

Liicke, on pacul osis, 180Ludw ig, vase -m o tor c entre of medulla, 23Lukomsky, ec chymo ses after suffoc ation,460

Lunatic s, gangrene o f lung in (Browne,Burm an) , 123Lund, exc is io n o f both astragali, 226Luneau, c ases o f emb o l ism , 13 5

Lung , ab scess o f the, cases and titles o fpapers , 122

—23gangrene o f the, cases and titles of

papers, 122—23

hydatids in the, case of (Zuber), 79Lungs , affections o f, from injuries tobrain (Brown-Sequard), 269brown induration of (Delafield, Rinddeisch), 121ec chym oses in , from injuries to thehead, experiments (Brown-Sequard),108

emphysema o f the, from injury to thehead (Brown-Sequard), 108encephalo id disease of (Sparks), 124epithelioma of the (Arnott), 124hydatids o f (Lebert, Zuber), 1242 5

hydatids of, in Australia (Bird), 125hypertrophy of, title (Thierfelder), 121

INDEX . 521

Lung, ill-cfiect on, from ill-developedmuscles Of neck (Kerner), 108inhalation o f dust into (Mayet, Ross ,Merkel), 123lymphatics o f the (S ikorsky), 11sc irrhous cancer of (Bennett, Waters),124

Lupus, papers o n, 187Luschka, cases Of c o llo id cysts in the

Lussana, nerves Of taste, 25Lutz, o n b rom ide O f po tass ium in epilepsy, 83Lymph , ab sorptio n Of, by tendons (Genersich , Lesser, 3—4flow Of, c ircum stances influenc ing, 4Lymph adenoma, case Of (Murch ison), 111Lymphadenomata, on (Wagner), 188

Lymp ln c orpuscles, glyc ogen in, wh ilem ob il e (Hoppe-Seyler), 8Lymph , glycerine, on , 431

Lymphatic varix, c ongenital (Paterson),211

Lymphatic s, arrangement Of, in serous

m embranes (Klein, Sanderso n), 4Of

'

the lungs, o n the (S ikorsky), 11Lymph oma, multip le, arsenic in (Billroth), 244Lymphomata, c ases o f (Ma ier, Roth), 188—89Lyons, on typhus in India, 56

Maa s, cases Of sporadic pellagra , 68

Operation for anchylo s is Of the lowerjaw , 230

MaeCall , on whoo p ing-cough , 117McCarthy, fo rmation Of artificia l anus inintestinal Ob struction , 296

McClinto ck , m ode Of removing uterinep o lyp i , 380

MacCo rmac , exc is ion Of sh oulder and

elbow in same arm , 213

experience Of gunsho t wounds, 263on gunsho t injuries Of b one, 264gunsho t wounds o f lower extrem ity,266

opening the stomach for cancer, 299

unreduced dislo cation Of the femur,253

McCoy, tumour Of antrum , 234

Macdonald, case o f shoulder presenta

tion, 414

on sunstroke, 58McDougall, haemorrhage after amputa

tion, 211

Macgillivray, case Of congenital hypertrophy, 438

McKee, reduction Of dislo cation of thefemur, 253

Mackenzie (Dr. , Of America) , case Ofemphysema during labour, 419

Mackenzie (Morell), treatment Of b ronch o cele, 237

Mackenzie (Mr. Stephen), on glycerinelymph , 431Mac lagan, intestinal les ion on typho id,5 2

Mac laren , on sea voyage in phth iSiS , 190Mac leod o n division o f pedicle inovario tomy, 305 , 390o n skin grafting , 335

McPherson, case Of b iliary calculus , 164Mac Swiney, case Of tubercular m eningitis , 89on infantile diarrh oea, 157

Madden, cases Of sudden death afterlab our, 424

Madge, paralys is during pregnancy,398

report on spec imen of ep ithelioma Ofuterus, 382

Magnes ium , ch lo ride of, ac tion Of, 462

Maier, cases Of lipomatous tum ours, 188

o n lead po ison ing , 99Malarial p o ison , vegetab le (Liveing), 37Malformatio ns o f foetus , influence Of

ammion on (Fiirst) , 393Malins , exc ision Of elbow for compound

dis lo cation, 218Malm sten, cases Of p o isoning by sulphuric

ac id, 441Mamma, on mode Of removing (Bell) ,234

rem oval, &c ., Of, 233—34Mamm ae, case o f four (Lorain), 371

cases Of haemorrhage from, supplemen

tary to menstruation, 373Manassein, s ize Of b lo od-c orpuscles at

different temperatures, 39s ize o f b lo od-co rpusc les in pyaem ia,&c .

, 6

temperature in animals after swinging, &c ., 39

Manizu, action of alcoho l on the tem

perature, 464

Manometer for resp irato ry movements(Wa ldenburg), 108

Marcet, b lo od a c o llo id fluid, 7chem istry Of muscle, 28

Marine grass for sutures (Burow), 349Marriage in c onsumptives , on (W illiams,Barnes , Bennett), 128Marshall, exc is ion in Old dislo cation Of

elb ow, 218

Martin, ep ilepsy from necro s is in th igh ,83

on puerperal fever, 421Martini, case Of muscular atrophy, 70treatment Of uterine disease, 402

5 22 INDEX .

Maschka, o n po isoning by sulphate Ofc opper, .443

Masius, on micro cythaem ia, 70sterc o -b ilin , 17

Mason (Mr. c left palate, 233removal Of w ire after Operation for

ununited fracture, 256Materia medica, rep ort on (Stevenson),46 1

Math ieu, am ount o f oxygen in b lo od indifferent arteries, 13

Matiejowsky, c ase Of stone, w ith ato nyof the b ladder, 276

Mattei, cramps during pregnancy, &c .,

409

Matthews, rem oval Of an artific ial too thp late from the oeso phagus, 287rupture Of the h eart, 144

Malton, pneumon ia during pregnancy,398

Maunder, exc is ion Of the ankle, 226exc is ion Of lower jaw thro ugh the

m outh , 235

o n primary exc ision Of the elbow, 216

Maurer, symptoms Of po isoning by van illaice, 452

on trich ino s is, 78Maury, extrovers ion Of the b ladder, 275Maxilla, inferior, anchylo sis Of the, operation for (Maas, Bottini) , 230inferior, cases of exc is ion o f, 228—29inferior, exc is ion Of, m ode Of per

form ing (Watson, Lizars), 228—29inferior, removal Of, through the

mouth 235

superior, exc is ion Of the, 229

Maxillse, superio r, resection of, fo r re

m oval of naso -pharyngeal tumo urs

(Bruns), 235Mayer, action Of strychnine on the b lo odpressure, 10

case Of soften ing Of the s tomach , 15 5Mayet, on anthraco s is, 123Mayo , on an o utbreak of typho id, &c ., 54

Mazza, on nervous pa lp itation Of the

heart, 147Mazzei, on cataract extraction, 343

Marzo lo , case Of s c iatic hernia, 293Meadows, on pelvic haematoc ele, 391Measles and smallp ox c o inc ident (Au

chenthaler, Brunto n), 60mortality o f (Bal let), 59treatment Of (Hofman), 58

Meadows, on treatment Of fibro id tu

m ours Of the uterus, 379Mediastinal growth, a pecul iar (Virchow),109

growth s, titles o f papers on, 112Mediastinum , carc inomatous mass in

(Clarke), 111 Micrococci in warts (Richter), 79

Medic ine, repo rt on (Shepherd) , 33Medulla o b lo ngata, vase-mo to r c entre ofthe (Ludwig), 23

Melano sis Of penis , (Ho lmes), 275Meldon, case Of injury to the head, 266Membrana nictitans , distribution Of nervesin the (Klein),

Membrane, resp ira tory mucous, h isto logyof (Bo ldyrew), 11

Men ingeal apo p lexy, titles Of papers on,89—90

Meninges , p samm omata Of the (Arno ld),188

Meningitis, c ereb ro -Spinal , on (E ulenberg,Ko tsono pulo s , Russell), 44—45do . , titles Of papers on, 44—45chro nic (Arndt) , 89Ophthalmo scop ic appearances in (Benchut, So c in, Broadbent, 90—91titles Of papers on, 89tub ercular (Flem ing, MacSwiney), 89

Menstruation, defective, On, 372early appearance Of (Ashton, Flugel) ,372

haemorrhage supplementary to , 373pa inful, 373

Menzel , o n disease Of j o ints from con

tinned res t, 325

ench ondroma Of the rib s, 241imp ac tion Of fo reign b odies in strictured (esophagus, 286

intra-buc cal resection Of the inferiormaxillary nerve, 328

Mercurial and lead po isoning, case Of

(Ho llis), 99Mercury, action Of b ich loride Of, 463

actio n o f, on secretion Of b ile (Bennett), 463Oleate o f, in treatment Of inflamma

tion, 334

sub cutaneous injections Of, in syph i

lis (S igmund), 308Merkel, inhalation Of dust, 123

o n Cheyne-Stokes ’s resp iration, 107o n structure Of muscle, 26

Mesenteric glands, anatomy Of (Popper),4

Methylam ine, o n (Lagrange) , 466Methylene, b ich lo ride of, use Of, 466Meyer, on action Of digitalis , 471

on ex0phthalmic go itre, 77value Of different kinds Of bread, 18Meynet, c ase o f s carlet fever, 61

case Of supp lementary haemorrhage,373

Mezger, sub cutaneous rupture Of vesselsin naevus , 211

Mialhe, chem istry Of hydrocyanic ac id,

5 24 INDEX .

Mus cular atrophy in children (E ulenb erg,Kno lly, Duchenne), 70—72atrophy, progress ive (Vogt, Gombault,Kno ll), 70—72atrophy, titles Of papers o n, 72exerc ise, effects Of (Flint), 31hypertrophy, pseudo (Mart in, Eulenburg, Kno ll , Duchenne), 70—72hypertrophy, pseudo titles Of paperso n, 72sense, on the (Bastian), 85spasm relieved by compress ion Of

arteries (Bro ca), 200MusculO-sp iral nerve, paralys is Of, after

frac ture (E rich sen), 2 56Mushroom s, chem istry

(Of (Ruckert) , 452

Mussels, o n

po iso nous (Bennie) , 453

Mussy (Gu eau de), a case Of aorticinsuffic iency. 130b ronch ial adenopathy, 110on hay fever, 43hyperaesthes ia o f the vulva , 386symmetry Of diseases Of the skin, 174

Myco s is endo cardii, case Of (Heiberg),140

Myelitis , chronic , c lass ification of, formsOf (Hall opeau), 93

Myo idem a (Ta it), 128Myoma Of uterus, 380

Myop ia , frequency o f, 342

Myxoma of the breast, spec imens, reference, 284

Naevi, removal Of, w ith the écraseur(West), 211

v us , subcutaneous, rupture Of vesselsin (Mezger), 211

Namias, on bromal hydrate, 466Nasal po lypus, death after extract ion Of

(Forster), 236po lypus , extractio n Of, b cuttingmaxillary bo ne (Lichtenberg 236

Naso -

pharyngeal tum ours , resection Of

m axillary fo r removal Of (Burns), 235Nasse, o n flow Of lymph , 4Navratil, o n laryngeal nerves, 102Neck, atheromato us tumours Of the,

removal Of (Schede), 243cyst Of, extirpated (Hardie, Atlee),237effects Of il l -develo ment Of musc lesOf, on lungs (Korner 108

gunsho t injury to , long retention Of

b all in (Barnes), 264tumours o f (s ee broncho cele) , 236, &c .

Necros is in jo int disease (Treves ), 325Of c lavic le, during scarlet fever (Kelly,Nowlan) , 61

Nedsvetzsk 1, on cho lera, 482Nephritis, on, 167—70

Nerve-centres, efl ects Of b eati andc oo ling b lood go ing to the (Fie

l

is, 22do ., influence Of, on ab sorption (Golz),4

glo sso -

pharyngeal, cas e of paralysis Of,(Taylor), 91inferior maxillary, intra-buccal reseetion of (Menzel), 328Optic (see optic), 90-91

Nerves, cases Of injury to , Of upper ex

tremity, 23

distributio n Of, in fishes (Pouchet,Beale) , 4distribution Of, in membrana nictitans(Klein), 24dis tribution Of, in wing Ofbat (Sohobl),24

effects Of stretch ing on exc itab ilityOf (S chlisch) , 21o n exc itab ility Of (Wi lly), 21exc itab ility Of, in various parts Of theirco urse (Rutherfo rd) , 21influence O f, on c irculation (Miescher) ,9—influencing deglutition (Waller, Prévo st) , 15laryngeal , function o f (Navratil), 102multiple tumours Of the, 188Of the lachrymal glands (Wo lferz),2 5

Of musc le (Héno cque) , 30of taste , o n the (Luss ana) , 25o f the tongue, o n the (l b lder), 25on the structure o f (Ranvier, Tamamischeif, E ngelmann) , 20—21senso ry , effects Of exc itation Of, o n

temperature Of b rain (Heidenhain),22

stretch ing o f, fo r cure o f spasm , &c .

(Nussbaum), 329term ination Of, in glands (Pfiuger),24

tro ph ic , on , 23

vaso -m o tor, distributed to arteries

(Ludwig) , 23Nervous centre, extrication o f heat

during ac tivity Of (Schifi), 22diseases, hereditary character o f

(Jastrowitz), 91do ., titles Of papers on, 100—1disorders from uterine disease , treatment o f, 402

system , Ophthalmo scope in diseases Of,90—91do ., papers on the, 24

Neub auer, detection Of pho sphorus , 454

Neugebauer, case of one-s ided haematom etra , 369

Neumann, absorption by the skin, 4

INDEX.

Neumann, ehauges in invo luntarymusclesof the skin, 17 3o n culture Of achorion , 185

developm ent Of sarc omatous growths ,187on syc o s is, 185

Neuralgia, titles o f papers on, 88Newm an, case o f ovariotomy, 301N icho lson, case Of injury to the head,267

Nico l, ino culation Of tuberc le, 38Nigetiet, production Of ac ids in musclesduring ac tion, 30

Nitric ac id , cases Of po ison ing by , 442NitrO-benzo l, po isoning w ith (Bahrdt),449

Nitrogen, effec ts Of diet and disease onel im ination Of (Parkes) , 18

N itrous o xide, on, 194Ox ide, po ison ing by (Purcell), 445

Noeggerath , case Of ab ortio n, 402p sammoma Of the uterus, 377

No let, on vascular murmurs , 10Norris, o n b lo od-corpuscles , 8

on passage Of c orpuscles through thewalls Of the vessels , 34

Norton, reduction Of dis lo cation Of the'

femur, 2 53

No se, vicarious haemorrhage from the,373

No tt a rectil inear écraseur, 244Nowlan, case Of s carlet fever, 61Noyes, self-opening s c is sors, 363Nunneley, on palp itatio n, &c ., Of the

heart, 145

Nussbaum , stretch ing Of nerves fo r cure

Of spasm, 329

O cular tens ion (Monnik), 338Odonto id pro ces s , m ode o f production Of

fractures Of (Sm ith), 259Oertel, experiments on diphtheria, 103(E sophagus , afi ec tions o f the, list o f

p apers o n, 152—5 3

haem orrhage from internal wound Of,287impactio n Of foreign b odies in strictureOf the (Menzel), 286rem oval o f artific ial to oth -plate fromthe (Matthew s), 287resectio n Of the (Billro th), 285spasm Of the (Paget), 285

Ogle (Dr. on right-handedness inanimals, 30

Ogston, c ase Of po iso ning by carb o licac id , 446

Oleranon, atrophy o f tricep s after frac

ture o f (Hutch inson) , 25 7Olier (M. case Of Caesarean section,412

5 25

on m ovements Of the uterus , 31

syph ilit ic ulceration Of intestine, 65Ossification Of the marrow Of b ones

(Demarquay), 332Osteo id c ancer Of ulna (Bell) , 244Osteo tomy, sub cutaneous, in anchylo s is

at knee (Little) , 225Otis (G. on re-a

‘

mputation at the h ip,212

O llivier, cases of croup , 106on c irrho s is Of th e liver, 161

O llier, o n skin grafting , 335O lshausen, c onception under unusual circum stances, 396

o n foetal perito nitis , 427Omb oni, on puerperal fever, 421Operations , statistic s Of, 196

statistic s Of, reference (Stokes), 234Oph th alm ia , po s t

-febrile, after relaps ingfever (Charteris), 5 7, 486sympathetic , on (Cohn, Mo oren), 35 5—61

Oph thalm ic medic ine, report o n (Carter,)337

Ophthalm o sc ope in brain disease, titleso f papers on, 91

in diseases o f the nervous system,

(Bouchut, So cin, Bro adbent) , 90—91Op ium , alkalo ids from (Hesse Rab uteau),468

antagonism of, to belladouna (Little),439

in cho lera, 50in conjunction w ith ch loroform, 468

large do ses Of, in diab etes (Kratschmer), 73

po is on ing by (Schaefer) , 452Op tic disc s in cases Of gunsho t injury tothe bra in (Cohn) , 352nerve sheath , drop sy Of, case (Bro adb ent), 90do ., haemorrhage into , in diphtheria(Classen) , 104

Orb it, amber mouthpiece of p ipe in

(Borel), 363gunsh o t wounds o f or near (Cohn),349—63

Orch itis after l ithotomy (Garden), 274from irritation in urethra (Hutch inson), 273f’pom stricture Ofurethra , case (Hulke) ,

2 2

Oré, strychnine antago nistic to ch loral,439

Organ ism s, presence of, in b lo od, 35Organs, func tio nal interchange(Ranke), 18

Os calc is , exc is ion Of the, 226—27Oser, cause Of the uterine m ovements,

526 INDEX.

Ovarian cysts, danger Of dra inage in

(Ph illips), 388do ., rupture Of (Palm), 388do ., sudden enlargem ents Of (Parry),388

do ., suppuration, operation on (Wells),391

do ., treatment Of suppurating(Ho lmes), 302disease w ith pregnancy, c ases Of , 399

’

tum our s imulated by enlarged uterus,

302

do ., s imulated by peritoneal inflammato ry cyst (Atlee), 304do ., s im ulated by uterine, 380—81tum ours , on diagnos is o f, from uterine(Wells, 381

Ovaries, malignant disease Of the

(Th omas , 388

Ovaritis, different fo rm s Of (Sc aglia), 387Ovario tomy after tapp ing an ovariancyst (C lay 305

cas es of Atlee), 305c lamps fo r (Atlee, Dawson), 390divis ion Of pedic le in , 305

during pregnancy, 391improved meth od Of dividing the pediele in (Mac leod), 390in a ch ild, 391in ch ildren, cases of, 301new c lamps for, 305statistics , 301do . Of (Wells, 388—91sub -

peritoneal , m ethod of securingvessels (Hayes), 390tors ion in (Beebe), 389tro char, a new (Tait), 390w ith removal Of fibro id Of uterus

(Panas), 390wound Of intestine during (Heath),305 , 389

Ovary, ab scess Of the, cas e Of (Edis) ,388

ab sence Of the, 371fibro id Of the (Waldeyer), 387hern ia Of the, o n (E nglisch), 291

Ovum, ex ulsion Of ent ire, at seventhm onth Brunton), 396

Packard, tracheotomy for paro titis, 322Paculo sis , 179—80Page, on skin grafting, 335Pagenstecher, extraction Of catarac t

w ithout Opening the capsule, 345on treatment Of ulcus serpens c orneas,348

Paget (Sir J removal Of tumours fromb one, 242

spasm o f oesophagus, 285

on strangulated hernia, 288

Palate, c left, Operations for, 232—33c left, use Of nasal muco us m emb ranein c lo sure Of (Lannelongue) , 334tumour of, remo val by divis ion of

jaw (King), 238tum our Of, rem oval through them outh

(Bickersteth), 239Palladium , ch lo ride Of, action Of, 462

Palm , cases of rupture Of ovarian cysts ,388

Panas , c ase Of ovario tomy, 390Pancreas, c irrho s is o f the (Pepper), 166Pander, detectio n Of emetine, bruc ine, ,

and physos tigm ine, 45 5Pangenesi s , o n (Galton), 3PanOphthalm itis, sympathetic (Cohn,Moo ren), 35 5—60

Pap illoma, cases Of (Gerhardt) , 181Pap illo n, ino culation Of tub erc le, 38Paracentes is in diagno s is Of abdom inaldisease, on (Sp iegelberg) , 392tho rac is , o n (Evans) , 113, 234do . (Béhier), 113do .

, case o f (Carter, Vallin, 112—13tho racentes is , titles Of papers on , 115

Paralys is after diphtheria, cases Of, 104—5agitans, patho logy Of (Murch ison,Cayley, Jo ffroy), 97do . , titles Of p apers o n, 98

fac ial, after ch orea (Buzzard), 81from injury in fracture (E richsen),256

infantile, c as es, 850. (Damasch ino ,Roger, 96—97Of arm after dis lo cation (Bernhard),247o f glo sso-pharyngea l nerve, case Of

(Taylor), 91p seudo

-hypertrOphic (E ulenberg,Kno ll, Duchenne) , 70—72w ith typho id (Clement), 5 3

Paras ites (animal , affec ting man), 77—79cutaneous , papers on, 187vegetab le, 79

Paras itic skin disea ses , 184—86Paraskeva, inoc ulab ility o f tub ercle, 38

Parkes , action Of al c oho l, 463effec ts Of diet and disease o n elim ination Of n itrogen, 18

Paro titis , tracheo tomy in (Packard), 322Parrot, on herpetic fever, 175Parry, enlargements Of ovarian tumours ,388

Parsons, cases Of co ncealed haemo rrhageduring lab our, 419

Parturition, cases Of po st-mortem (Aveling) , 410

a ou the effic ient powers of (Dunean),406

5 28 INDEX ;

Phth is is, identity Of grey and yellowtub ercles (Mo xo n), 125interm itten t pyrexia in, deno ting ah

sorption (Duhrrsen), 127muscular irritab ility in, on (Ta it), 128on c lim ates fo r (William s) , 127on m arriage in tho se affected w ith(Williams , Barnes, Bennett), 128o n N iem eyer

’

s views on (FOX, Ko r

ner, Kennedy, Sko da), 126o n spurious (Co ndie), 125a tho usand cases Of (William s), 127starting-

po int fo r, in a thousand cases

(W illiam s), 127titles Of papers on, 128

Phys io logy, repo rt o n (Power) , 1Physostigm ine and strychnine, on antag onism Of (Ashmead), 440antagonism Of, to atrop ine (Fraser) ,434

o n detec tion Of, 45 5

P icro toxin, ac tio n Of (Povergo), 452on detection o f (Blas, Depaire), 45 556

P igmentation Of the skin, papers on, 187P ilz, on tem perature, 39P incus , on alopec ia, &c ., 184

P irrie, o n ac upressure, 197P ityrias is p ilaris , c ase Of (Fo x), 177Placenta, anatomy Of the human (Hicks,Joul in), 393—94

calc ificatio n O f the (Frankel), 394cysts Of the (Jacquet), 394exchange o f gases 1D, im itation o f

(Bernstein), 14mechanism Of the expuls ion Of the

(Duncan), 407succenturiata, 424

Plas ter o f Paris in fractures (St. John) ,2 5 5

Playfa ir, cause Of irritab le b ladder duringpregnancy, 398

sudden death a fter lab our, 424Pleasanton, influence Of vio let ligh t o ngrowth , 18

Pleurisy, case Of (Renault), 114cases Of thoracentes is in (Jo nes, Redenb acher, Paul), 112diaphragm atic (Hayden), 114explanatio n Of pain (Hus s) , 112m odes Of operating for (Bouchut),113

titles Of papers on , 115Pleuritic effus ion o n Operation in (Béh ier), 113

Pneumatic aspirator (see a sp irator),113—15

Pneum onia, ac tion Of alchOhOl in, 464chro nic , relation Of, to phthis is (Fox,Kerner, Skoda), 126,

Pneumonia during pregnancy (Malton),398

etio logy o f 118experiments on 119interstitial (Green), 120do ., rap id fo rm ation Of, and Of falsem emb ranes (Brouardel), 120lowering O f vital ity in (Farquharson),118

nature Of (Revil lout) , 118Often m istaken for o ther a ilments(Fitzmaurice), 118sudden dea th during c onvalescenccfrom (Hayem ), 119syph ilitic (Moxo n), 120temperature, &c ., in (Leb ert), 119titles Of papers on, 121treatment Of, neutral acetate Of leadin (S troh l), 120

Pneumo th orax, titles Of papers on , 115

Podo linski, on po isoning by carbo nic oxide,444

Po ison Of animals, infection from, l ist ofauthors o n, 42

Po isoning by ac ids, c ases Of, 442by ammonia, case o f (Stevenso n), 442by carb o lic ac id, on , 446

by carbonic oxide, on (Zuntz, Donders,443

by caustic po tash , c ase Of (Nager),443

by copper, On, 443

by lead, on chronic (Heubel), 442by nitrate Of s ilver, c ase o f (Scattergo od), 44 2by Op ium (Schaefer) , 452by oxysulph ide Of carb on, 444

by pho sph orus , o n turpentine in, 440by sulphate Of c o pper (Mas chka), 443by sulphate o f zinc (Tardieu) , 443by sulphuric ac id, c ases Of, 441by vanilla ice, symptoms Of (Maurer),45 2

w ith ch lo ral hydrate, cases Of, 449w ith nitrO-b enzo l (Bahrdt), 449

Po isons, on ab so rption Of (Go ltz), 433animal, m o de Of c ontagion by, 3 5 - 37antagonism Of, 011, 434

detectio n Of, 4 54—5 6efl

’

ec ts o f certain, o n heart’s actio n

(Schm iedeberg), 10o n elim inatio n Of (Austis ) , 434snake, on (Fayrer, Richards), 453various, antagonism Of, o n (Reese),438

Po isonous action Of fungi (Husemann),453

mussels , on (Bennie), 453Po llak, haem orrhage from the kidneys ininfants, 432

529INDEX.

Pollard, dislo cation o f bo th femora, 254Po l lo ck, case o f psorias is, 176Po lypus, nasal, death after extrac tion o f

(Fo rster) , 236do ., extraction o f, by sawing maxil laryb one (L ich tenb erg), 236pharyngeal, remova l o f, w ith galvanicc autery (Corradi, G o zzini) , 236

Ponti, c ongen ital c o loboma o f the iris,339

Po o ley, ab scess of the tongue, 284fibrous tumour o f the tongue, 284Po ore, intens ification of sounds o f heart,130

POpofi , on cho lera, 481experiments on pneum onia, 119

Popp, on diaphragm atic hern ia, 290Popper, mesenteric glands , 41treatment of typh o id, 5 5

Porro , c ase o f c o ngen ital atresia of theoesophagus, 152

Porter, case o f acute atrophy o f the liver,161

suc cessful reduction of pro lap sedfunis,412

Po tash, caustic, case o f po isoning by

(Nager), 442Po tass ium , brom ide o f, in ep ilepsy(Vance, Lutz), 83do ., in vom iting o f pregnancy (Gimbert), 400ch lo ride of, ac tion of, 462

iodide of, c aus ing pemph igus (Bumstead), 176

Pouchet, distribution o f nerves in fishes,24

Poulet, detection of pho sph orus, 454:Povergo , actio n o f p icro toxin, 452Power, report on phys io logy, 1Pregnancy, anaem ia during (Gusserow),397causation o f heart disease during

(Lebert), 397chronic heart disease w ith (Sp iegelb erg), 398diagno s is of, on (Hicks, Wa llace), 401duration o f (Duncan), 401extra -uterine, cases o f (Perroud), &c .,

403—4in c ase o f doub le uterus, 399influence o f uterine fibro ids o n , 411

interstitial , case o f (Edgar) , 404:irritab le b ladder during , on cause o f

(P layfair), 398o n album inuria during (Kaltenbach) ,396

o n cramp s duringon the vom iting o f (Hevvitt, 400

paralys is during (Madge); 398

pneumonia during, on (Matton), 398

Pregnancy, preco c ious, cases o f, 405recurrent dis charge from the uterus

during (Brown), 394relaxation o f pelvic articulatio ns during(King), 407treatment o f vom iting in, 400under unusual c ircum stances (Olshaus en), 396ves ic al fistula in case o f, 398

w ith ovarian d isease, c ases , 399Prestel , on drinking water, 490Presysto lic c ardiac murmur (Barc lay,Balfour), 131Presysto lic murmur, on the (Fagge) ,140

Prevo st, nerves of deglutition, 15Preyei , on actio n o t hydro cyan ic ac id,446

on the crystals o f the b lo od, 5on detec tion o f b lo od, 459detection of hydro cyanic ac id, 45 5

Priap ism , pers istent, case of (Mackie),273

Priestley, on intermenstrual dysmenorrhoea, 374

Progress ive muscular atrophy (Charcot),95

do . atrophy, cases , &c . (Martini, Vogt,Gomb aul t, Kno ll), 70—72

Pro state, enlarged, o n (Quain), 274irritation o f th e, caus ing o rch itis(Hutch inson) , 273

Proto zo a , transmutation of fo rm in cer

tain (Johnson), 3Prurigo , c ases o f (Wilson), 178h isto logy o f (Gay), 178

Pruss ic ac id (see hydro cyanic ac id)Psammom a o f the uterus, 377Psammomata, o n (Arno ld), 188Pseudo -leukaem ia and leuco cythemia(Wo od), 69

Pseudo -muscular hypertrophy, 70—73Psorias is guttata, case o f (Po llo ck), 176papers o n, 186

treatment o f (Buck), 176Pterygo

-m axillary tumours, removal of(King, Bickersteth), 138—39

Ptyal in, action o f, o n starch (Paschutin) ,16

Puccioni, remova l o f the tongue w ith thegalvan ic w ire, 283

Pudzinowitsch , relation o f persp iration totemperature, 40

Puerperal c onvuls io ns, cases of, 424fever, on (Martin, 850. 421

fever, on 398peritonitis , on, 423septicaem ia , on , 422

Pullar, case o f hydatid cyst o f cerebellum,

93

5 30 iNDEX'

.

Pulmonary artery, steno s is o f the, a fterb irth (Paul ), 142

Pulsatio n, instrument for audib ly measur

ing (Jacob s on), 129Pulse, dim inished frequency o f, b efore

death from com a (Gray), 133Purcell, p o ison ing by nitrous o xide, 445Purpura, titles o f papers on, 75

Pus, large bod ies found in (Bizzo zero),34

o rigin of, from wh ite co rpuscles, on

(Duval), 7 , 34Pyaem ia, autop sy o f a pig suffering from(2) (Ro th), 74

Pyaem ic symptom s w ith stricture of

urethra, &c . (Hulke), 272Pye Sm ith , ca se o f congenita l m alfo rm a

tion o f the heart, 148

Pyoko lpo s lateralis , ca se o f, 37OPyometra, case o f, 370

Pypingsko ld, vom iting in pregnancy,

Quadruplets , cases o f, 412Quagl ino , value of iridectomy in glauc om a , 347Quain affections of the walls of

the heart, 137on fatty degeneration and rupture

o f the heart, 143

Quain o n enlarged pro state, 274

Quehl , on apomo rph ine, 469Quincke, effect of insp iration o n current

o f b lo od through the heart, 13Quinine, action o f, on wh ite corpusc les(Geltowsky , Kerner, Binz), 7arsenate o f, on (G iov), 463in ch o lera , 48—50

Rabagliati, statistics of cancer o f breast,233

Rab ow , ac tion o f al coho l o n temperature,464

Rabuteau, o n alkalo ids from op ium , 468

o n op ium w ith ch loro fo rm , 469

on use of ch lorides, 462do . sulph o -vinate of so dium , 461

, Radcl ifi e, (Mr. J . Netten), on the spread

o f ch o lera, 472—77Radius, fracture of head of (Adams), 258Radziejewski, on oxysulph ide o f carbon,

Ranke, on functional interchange, 18Rans ome, mechan ical conditions of resp i

ratory m ovem ents , 14Ranula, fatty m asses in a (May), 284Ranvier, structure of nerves, 20Rasch , method of us ing uterine sounds,Ratclifi

'

e (Netten),on outbreak of fever, 54

Rattray, on change of c limate, 14; 190Raym ond, o n typh o id, 83Re-am putation at the hip , on (Otis),212

Rec tal fo ssa, rem oval o f p iece o f b one

from th e (Thom pson) , 300litho tomy o n (S chaffer) , 278

Rec to ves ica l fistula, co lotomy fo r

(Bryant), 299Rectum , c ongen ital invag ination o f the,432

stricture of, co lo tomy in, 299

stricture o f the, treatm ent o f, 299

Redenb acher, case o f pleurisy, 112c ases of hydatids o f b ra in, 78—79

Rees (Owen), diagnos is o f syph i litic disease o f b rain, 65

Reese (Prof ), o n antagonism of variousp o isons, 438

Refraction, o cular, frequency ofdefects of,342

Reich , on typho id, 488Reichard, on ch o lera, 50Reimann, difficult lab our from pres ence

o f two foetal heads, 411on the innervation of the uterus , 405

Reincke, po st-mortem on case of leuchaem ia, 69

Relaps ing fever (see fever)fever, Oph thalm ia after, 486

Renal c apsules, supra changes in, 76Renault, case of p leuritic effus ion, 114Rendle, po plitea l aneurism on bo th sides,cured by compress ion, 210

Renzy, o n cho lera , 50o n typh o id, 484

Resec tion (see excis ion) , 213Resp irat io n, action o f the heart on

(Lando is , Ceradini), 13artific ial, o n, in injuries to the head(Sch iff), 14auth ors o n, 15

effects o f divis io n of sp inal c ord on

13

effects o f, on c irculation (Quincke,13

effects o f, on heart’

s action (Hering);10

influence o f atmo spheric pressure on(L ieb ig), 15pendulum-like, on (Bruchner, Meikel),107titles of papers on, subjects cons

nected with , 109volum e of exp ired air in, experimentson (Leichenstein), 11

Resp irations, manometer for (Waldenburg), 108

Resp iratory movements, mechanics ofthe (Ransome, 14

532 INDEX.

Salleron , dislo cation of the b ones of the

p elvis, 249Salter (Hyde), auricular pericardial friction, 130

Salts , alkaline, el im ination of, from the

b ody (Salkowsky), 19Samt, autop sies o f two aphas ics , 86Samuel, experiments on injectio ns of

various secretions , 34Sanderson (Dr. Burdon), o n development

o f b acteria, &c 2

development of m icro zym es, &c ., 36

o n sero us memb ranes , 4

Sarc inae in b lo od (Lo sto rfer, Ferrier,Bastian), 36

Sarc ina not a living organism (Bastian),36

Sarcomata, development of (Neumann) ,187

Sargent, case o f diaphragm atic hernia,2 90

Savory, cases o f po pliteal aneurism , 209

case o f sanguineous tum our o f the

neck , 238Sawicki, am ount o furic ac id excreted bythe kidney, 30

Sayre, o n treatment o f hip-j o int disease,326

vertebrated catheter, 272

S cab ies , treatment of (Monti, Weinberg),185—86

S caglia, on the different forms of ovaritis, 387

Scapula, exc is io n o f portio n o f the (Hill),231

exc is ion of the (Spence), 231Scapulo -humera l periarthritis , on (Dup lay), 332

Scarlet fever and smallpo x co inc ident(Brunto n, Sans om), 60and varicella c o inc ident (Brunton,Musket), 60at the age of fifteen days (Meynet), 61ep idem ic s o f, &c . , 487haem atoma in case o f (Huber) , 60morb id anatomy of , and relation to

enteric (Harley) , 61fever, m o rtal ity o f (Ballo t, Fleischmann), 59necro s is o f c lavic le during (Kelly,Nowlan), 61o rigin o f (Carpenter) , 60rheumatic , titles o f papers on, 43titles of papers on , 61

treatment o f (Ho fmann) , 58S cattergood, case o f po isoning by nitrateo f s ilver, 442

Schaefer, po isoning by op ium , 452S chaffer, on rectal lith otomy, 278Schapringer, effect of tensor tympani, 25

Schatz, case o f defo rm ity o f the urindt

genita l system , 371

cases o f incomplete unio n o f the

female gen ital organs, 371Schauenburg, c ases o f po iso ning by sul

phuric ac id, 441Schede (Max), removal of atheromatous

tum ours o f neck, 243S ch iefferdecker, cases o f injury to nerveso f th e upper extrem ity; 23

S ch ifi , art ific ial resp iration, 14on extrication of heat during activityo f b ra in, 77func tio ns o f sp inal c ord, 21influence of sec tion o f c ord o n resp iratio n, 13

Sch iffer, c o agulatio n o f the b lo od, 7Sch leissner, on ch o lera, 49Sch les inger, cause of the uterine movements, 406

Sch liep , on dilatation of the stomach , 154Schlisch , o n effects o f stretch ing of

nerves, 2 1S ch loemann, on cho lera, 50Schm iedeb erg, actio n o f certa in po isonso n the h eart, 10

S chm idt, cause o f the co agulation of theb lo od, 7

Schehl, term ination of nerves in b at’s

w ing, 24S ch o lz, treatm ent of typh o id, 54Schultze, c ases o f ovario tomy, 390

on still-bo rn infants, 425S chultzen, on pho sph o rus p oison ing, 440Schutz, treatment o f diphtheria, 106Sc isso rs for removing sutures (Sm ith),233

self-opening (Noyes), 363S clero derma, cases of (Curran, Dufour),179

papers o n, 187

p o st-m ortem appearances in (Fagge),178

Sclerias is (see scleroderma), 178Scurvy, analys is of the b lood in (Chal

vet) , 8cases o f (Hayem), 7 5ep idem ics , &c ., o f, 490exam ination o f b lo od in (Chalvet), 75titles o f papers o n, 75

Sec retions , results o f injection o f various(Samuel), 34

Seegen, o n presence of sugar in normalurine, 172

Seitz, case o f multiple tumours of nerves,188

Senator, ab scess o f lung, 122interm ittent and relaps ing fever, 57Senses, spec ial, papers on the, 25Septicaem ic po isoning, mode o f, 36—37

INDEX .

Septicaem ic po isoning, s ize of red cor

puscles in (Manassein), 6Sero us m embranes, ab s orptio n o f so l idsby (Auspitz, Neum ann), 3do .

, arrangem ents of lymph atic s in(Klein , Sanderson), 4

Sésary, study o f maximum temp eratures

o f hea lth reso rts, 190

Shepherd, hydatids o f kidney, 171rep o rt on medic ine, 33

Sherman, case o f rupture o f the heart,145

Shoulder, dislo cation of (s ee dislo cation),247exc is ion o f the (see exc is ion)

S ichel, c ircumsc rib ed ch o ro iditis, 366o n h erpes frontalis, 175

S igmund, on sub cutaneous injec tio ns o f

m ercury in syph ilis , 308S iko rsky, lymphatic s of the lungs, 11S ilbert (Vincent) , o n apom o rph ine, 469S ilver, n i trate o f, c ase o f p o is oning by(Scattergo od), 442

S imon, on aphas ia, 87c ase of heart disease, w ith emb o lism ,

&c ., 141

on gummata in liver, 66prodromal exanthem of sm allpox, 62

S imp so n, o n cancer of uterus, 383

S inging, power o f, w ith aphas ia (Jacks on), 88

Skin, ab sorption by the (Ausp itz, Neu

m ann, Rohrig), 3—4a ffections in pellagra, 67am ount o f carb onic ac id elim inatedfrom the (Aub ert), 14b acteria in, in smallp ox (Weigert), 63b ro nzing o f, cases o f, 76

ch anges in the invo luntary muscles o fth e (Nsum anu), 173disease o f the, c ases of, statistics o f

(Smith , Anders o n), 173—74diseases of the, list o f papers on, 186—87do ., symm etry o f (Mussy), 174disturbances of the secretio ns o f th e,183

grafting, on (Ollier), 335imb ib itio n o f p o isonous fluids through(Bennett), 37parasitic afi ections o f th e, on, 184—86th icken ing o f the, case o f curious(Ul lersperger), 179

Skoda, o n phth is is , 126Sko ldberg, c ases o f ovariotomy, 389Skull, ab s ces s w ith in the, treph in ing for(Sm ith), 268frac ture o f (see fracture)gunsh o t injuries o f the, 265

Smallpo x, albuminuria in (Cartaz), 63

5 33

Smallpox andmeasles co incident(Auchenthaler, Brunton), 60and s carlet fever c o inc ident (Brunton,Sansom ), 60b ac teria in skin in (Weigert), 63carb o lic a c id in (Salkow ski), 445c ase o f ino culation o f, 431

cause o f death from (Huchard), 63ep idem ic s o f, &c . , 487

extravasations in , on (Wyss), 63h aem o rrhag ic , after lab o ur, 423incub at io n o f, in utero , 432

in a foetus, c ase o f, 432

m ode of formation, &c . , o f pustules of(Vulpian), 63m o rtal ity o f (Ballo t), 59nervine symptom s o f (Gub ler, Lab o rde), 63preventio n o f pitting in (Revil lout) ,63

prodromal exanthem o f (S imon), 62relation of, to varicell a (Rommelaere),63

titles o f papers on, 64unsymm etrical (Clemens), 62

Sm ith (Angus) o n air and ra in , 491

Sm ith (Dr.) c ase o f ab sence o f the uterus

and vagina, 371o n ankle-jo int amputations (American),213

Sm ith (Henry), c ase o f passage o f artifi

c ial to oth-

p late along alimentary canal ,287laryngo tomy for rem oval of foreignb ody, 320

Sm ith (Dr. mode o f productio n o f

fractures o f odonto id pro cess , 2 59Sm ith , c ase o f disease of the heart, 138

c ases o f skin disease, 173Sm ith (R. treph in ing for ab scess

w ith in the cranium , 268

Sm ith (R. o n incomplete fractures,2 5 5

supra-sternal dislo cation of c lavic le,

246

Sm ith (Spencer), c ompound dislo cationof fo o t, 255

Smith case of vac cm o -syph ilis, 306on c left palate, 232open ing the s tom ach for cancer, 299s c isso rs for removing sutures, 233

tub ercular disease o f urinary muc ous

m embrane, 269

Sm oke and dust, o n (Tyndall), 2Snake po iso ns, o n (Fayrer, Richards), 453Snel ling, sub clavian b ru it, 132So cin, Ophthalmo scop ic appearances inbrain disease, 90on typho id, 483

Sodium , ch loride o f, use of, 462

5 34 ~ INDEX .J

Sodium, on use of sulphovinate o f (Rabuteau), 461

So lids, ab sorption o f, by serous mem

b ranes (Ausp itz, Neum ann) , 3So lowieff, 011 dysmeno rrh oea, 373

Sommerbrodt, experiments on phth is is,126

Sonnenschein, on detection o f b lo odstains, 45 8

So rby, on the spectro scopy of b lo od, 459So usino , dyspep sia for starchy fo od in

infancy, 429Southey, intestinal ob struction for c on

genital co nstriction, 295Sparks, primary cancer o f the lungs, 124Spectro scopy o f b lo od, on the (Sorby),459

Speech , cerebral mechanism o f (Bro adbent), 84defect o f, with c onvuls io ns (Jackson),87lo s s of, cases o f (Baginsky, S imo n,

Jackson), 87lo s s of, on (Bristowe, Hammond), 86- 87lo ss o f, titles o f papers , on, 88—89unaffec ted, w ith right-s ided hem ip legia (Down), 88

Spence, case o f fusifo rm femora l aneurism, 209

exc ision o f the s capula, 231cases o f fals e aneurism , 2 10

Sperling, injections into the arachno idcavity, 89

Sphygmograph, o n a cardio (Garro d), 9Sp iegelberg, cases o f distortio n o f the

pelvis, 410diagno sis o f cancer o f uterus, 382paracentesis in diagno s is o f abdom i

nal disease, 392pregnancy and heart-disease, 398

Sp inal co rd, anatomy o f th e (Dittmar),31

Sp ina b ifida, cure o f, by tapping, &c .

(Cabrai, Morto n), 326Sp inal affectio ns , titles o f papers on,

95—96co rd, on chronic inflammatio n o f the

(Hallopeau), 93co rd, effects o f divis ion of the (Riegel),22

cord, effects of divis io n of, on resp1ra~

tion (Leichtenstein, S ch iff), 12—13c ord, functions of, as a co nductor

21

c ord, h isto logy o f, in tetanus (Allbutt,Jo ffroy), 98hem iplegia, cases o f (Fieber), 84infantile paralys is, cases o f, &c .

(Damaschino , Roger, 96—97

Sp inal cord, on i rritative les ions o f the'

(Charco t), 95m eningitis , o n, 43—45

Sp ine, dislo catio n o f (s ee dislo cation)fracture of (s ee fracture)

Spleen, afi ec tions o f the, autho rs o n, 165—66c ourse o f the b lo od in the (Wedl,Sto if, Hes se), 19d isease of the, w ith leuc o cythem ia(Wo od), 69function o f the (Mo s ler), 19s ize o f, in ch ildren (Steffen), 165

Sputum , pecul iar (Wh itehead), 109Square, case o f haemo rrh age after lith otomy, 277removal o f lo o se cartilages from kneej o int, 326

Squarey, cases o f ab sence of uterus, 371

c ausation of acquired flexio ns of the

uterus, 384

Squire (Balmanno ), on paras ite in m o l

luscum c o ntagio sum , 182

Squire direc t ingu inal hern ia inthe female, 288

Squire (Dr. vertebrated catheter, 272

Staphylo raphy, 232—33

Stap les , amputation at the knee-j o int,213

S tarch , actio n o f p tyalin on (Pasehutin),16

w ide diffu s ion of a ferment acting on

(Lepine), 16StauungSpapilla, 353

S tefi en, on h o op ing co ugh , 117o n s ize of liver and spleen 111 ch ildren,165

Steiner, b loo d in peritoneal cavity in newbo rn ch ildren, 165

Steinm ann, rap idity o f current in veins, 9S teno s is o f pulmo nary artery after b irth(Paul), 142

Stereo b ilin, on (Lair, Masins), 17S tern, case o f imperforate anus, 299

Stevens, case of interm ittent hwmaturia,170

Stevenson, case of po isoning by nitricac id, 442repo rt on m ateria medica , 461report on medical jurisprudence,repo rt on pub lic hea lth , 472

Stricker, on keratitis, 33Stric ture di lator, a new (Hill), 272

o f the oesophagus, spasm od ic (Paget),285

o f urethra, perineal section fo r, caseo f (Hulke), 272o f the urethra, on (Stokes), 272do . (Th ompso n), 272

Stoff, course of b lood 1n spleen, 19

5 36

Tar, on adm inistration o f (MagnesLahens) , 467Tarso -metatarsal j o ints,(Ho lmes), 227—28Taste, on the nerves of, 25

Tay (Waren), case o f intestinal ob struct ion, 294ca se of haem orrhage after l ith otomy,277c ongenital fibrous tumour o f arm,

exc ision of

fatty m atter in a ranula, 284report o n surgery, 193Taylor, case o f embo lism , 91

case o f intestinal ob struction from a

knot, 295on dactylitis syph ilitica, 308on mechan ism o f uterine invers ion,418

Teake, removal o f plate of bone from thelarynx, 321Teak le, tumours o f dura mater, 93

Teeth, developm ent of, in rickets (Fl eischmann), 7 5Temperature, action o f alc oho l o n the,464

efi ects o f alterations o f, on s ize of

b lood-disc s, 39effects o f exerc ise on the (Al lb utt,

15 , 40

effects o f, o n the heart (Brunton), 133in anim als during movements (Man

a ssein), 39in healthy(Pilz), 39in rickets (Ritch ie) , 7 5increase o f, w ith intense headache

(V ergely), 40influence o f h igh, on low o rganism s(Burdon -Sanderson, 2

l ist o f autho rs o n, 41lowering o f the, b efo re death, 40

relation b etween persp iration and the

(Padzinowitsch), 40Tempo ra l bone, periostitis of the (Hutchinson), 333Tendons, ab sorption o f lymph by (Genersich , Lesser, 3—4Tennent, cas es o f relap sing fever, 5 7

on relap sing fever, 486Tens ion, o cular, m ode o f testing, 339Tenso r tympani, action of the (S charpringer), 25Teratoma myomatodes (Virch ow), 109

Terry, cases o f exc is ion o f the knee, 223excis ion o f the o s calc is, 227Testis, cancer of imperfectly descended,on, reference (Arnott), 281

-

2

removal of, for neuralgia (Annandale),81

ch ildren during day, &c .

INDEX .

Testis, trans ition o f, into perinaeum

tub erculous , treated w ith actual cautery (Verneuil), 281Test types (Burchardt), 343Tetanus , fatal c ases of, a fter abo rtion,403 z.

h isto logy o f cord in (Allbutt, Jofiroy),98

quantity o f album inous c ompounds inmusc les in (Danilewsky), 27neonatorum , 428

titles o f papers on, 98—99treatment of, by various drugs, 98Th igh , fractures o f the, in the newlybo rn, 427Thigh -b o ne, sub cutaneous d ivision ofneck o f (Adam s), 234Th in, on sunstroke, 58Th inking, phys io logy o f (Bastian) , 85Th omas (Ga illard), on ch loro sis, 372

on enucleation of sess ile uterinefib ro ids , 378malignant disease of the ovaries, 388exc is ion of half o f lower jaw , 229

Thompson, actio n o f ergo t o f rye, 421

ca se o f intra cranial o steophytes, &c .,

89

o n ch o lera, 49o n dilatation of the heart, 138

rupture o f the heart, 144

Thompso n remo val of p iece o f

b one from the recta l fo ssa , 300Thompson (Sir cho ice o f operationsfor sto ne in the b ladder, 276improved flexible catheter, 271on prevention o f cal cul ous disease, 279rem oval of p iece o f bo ne from the

b ladder, 2 77o n stric ture of urethra, 272

Thought, cerebra l m echanism o f (Broadbent), 85o n the mechanism o f (Bro adbent), 25Thoracentes is (see paracentes is), 112titles of papers o n, 115

Thorax, carc inomato us mass in (Clarke),111

growths in, 109—12

growths w ith in, titles of papers on,

112

Thrombo s is , titles o f papers on , 136

Tib ia , bullet in head of (Sto kes), 208Tilt, on hysteria, 80uterine inflammation after the changeo f life, 392Tinea (s ee paras ite)Tob ac c o , o n texico l ogical efi ects of

(Vohl), 450smoke, chem ical constituents o f (Vohl,Huebel), 45M 1

INDEX

Tongue, ab scess o f the (Po o ley), 2841cases of removal o f the, 2841congen ital hypertrophy of the (Law .

[

son, S imon , Clarke), 2841fatty tumour under the (Churchill),284

fibrous tum our of the (Po o ley), 284!on the nerves o f the (Lussana,Ihlder), 25new method of removing (Jordan),283

removal of, for ep ithelioma , by galvanio w ire (Go zzini, Puccioni), 283unilateral atrophy o f the (Clarke), 335Tonometry of the eyes (Monnik), 338Too th -p late, artific ial, extraction o f, from

the oesophagus (Matthews), 287artific ial, passage of, along alimentarycanal (Sm ith), 287Torsion o f arteries (Callender), 198

T ouch, on the comparative anatomy of

the organs o f (Job ert), 2 5T o urniquet, doub le, a (Bulley), 210Townsend, case o f aneurism o f the leftventricle, 139

Trachea, stricture o f the (Trendelenburg), 324tube rem oved from the, 321 —22

Tracheal tamp on, o n the (Junker), 319Tracheotomy for paro titis (Packard), 322for removal o f foreign bo dies, cases of320- 21

in croup , cases of, 105—7

in diph theria, cases o f successful, &c .

(various), 104—6m laryngeal o b struction, cases o f

(Bo elt, Rus sell), 101tub e, rem oval o f by operation, 32122

tw ice in the same person (Stokes), 321Tracy, cases of ovariotomy, 390Transfus ion , cases o f suc cessful, 419

—20instrument for (Aveling), 419in uraem ia (Stohr), 170o f b lo od, on, 329

on (Richardso n), 420Transmutation o f form in certain pro

tozoa (Johnson), 3Traub e, o n b lo od in urine, 173

c ase o f b ronch itis , &c ., 116

Traumatic erysipelas , on (Wilde), 318fever from gunsh ot wounds (Hueter),315

fever, on (Billro th), 311Trendelenburg , on stricture of the

trachea, 324!

Trenh o lme, on irregular, ’ c ontractions ofthe uterus, 408

Treph ining for ab scess w ith in the cra

n ium (Sm ith), 268

5 37N

Treph ining for gunsho t (Halstead,Howard) , 265in c erebral disease (Pepper), 268o f skull for fracture, cases of, 266—68

Treves , exc is ion o f the knee-j o int, 222on j o int disease, w ith necro s is , 325

Trial, the Wharton-Ketchum , 456

Triceps , atrophy o f, after fracture of theo lecranon (Hutch inson), 2 57Trich ino s is , cases of (Udb c , Kittell,Maurer, Zenker), 7 ’7—78in rats (Zenker) , 78titles o f papers o n, 79Trismus nascentium , on (Bailey) , 428Troup , opening the stomach for cancer,299

Tub erc le, identity of grey and yellow(Moxo n) , 125ino culab ility o f (various), 38—39o f b ra in, case o f (Fleischmann) , 92o f the cerebellum (Cordier, Jackson),92

Tuberc les in the choro id (Frankel) , 91Tubercular disease o f urinary mucous

memb rane (Sm ith) , 269m eningitis (see m en ing itis) , 89Tuberculo s is after typho id (Birch-Hirschfeld), 39experiments on (various), 38 -39on (Korner), 108relation of, to pneumonia (Fox, Kor

ner, Skoda) , 126Tucker, m eth od o f delivery in arm pres cutation, 414

Tuckwell , case of Addison’s disease, 76c ases o f cho rea , 81

ringworm o f cattle communicated tom an, 79Tum our, congenital fibro -cellular, o fbuttock (Bryant) , 2 413c ongenital fibrous, of arm (Tay),243

cystic , of neck, removal of (Hardie,Atlee) , 237cystic , sanguineous, of neck (Savory),238

fib rous, of the tongue (Po o ley), 2841fibrous, rem oved after labour, 419o f antrum , from c anine to oth (McCoy),234!

o f antrum from distens ion, reference

(Haward) , 235of lower jaw, myelo id (Maunder),235

of palate, removal o f, by dividing jaw(King), 238do ., removal o f, through the mouth

(Bickersteth), 239 0

peculiar, from abdom inal cavity, 189scrotal , removal (Bickersteth), 243

5381 INDEX;

Tumour, atheromatous, o f neck, removal Typhus , on war”

(Virchow), 56of (Schede), 243 o n cereb ro -sp inal meningi tis , case of

cystic , of b reast , reference, 234 (Campbell) , 5 64 development o f (Ncumana) , 187 spread of, &c ., 485

intracranial , cases , and titles o fpaperso n, 92—93mediastinal, 109—12do ., titles o f papers on, 112

naso -pharyngeal, resection o f axillaefo r rem oval o f (Burn s) , 235heart, 233—3 4papers o n, 190

rem oval of, from bone (Paget), 242treatment o f, b y sub cutaneous injection (Heine), 244Turner, po isoning by carb onic oxide,

Turning, cases o f, 415impo s s ib le in a case o f shoulder prescutation, 414in defo rmed pelvis, 411Turpentine, o n ab so rption of, 467ab sorptio n of, by the unbroken skin(Rohrig) , 4o il o f, in pho sphorus po iso ning, 440

Tympanites, on gastro -intestinal puncturein, 157Tyndall, on “

dust and diseas e, 37on dust and smoke, 2

Typho id, causes of (Mas sachusetts report),5 4

- changes in intestine in (Murch ison,

Maclagan), 5 2emac iation in (Allbutt), 5 2from spec ial po ison, alvine (Latham),5 3

haematoma during recovery from

(Guéniot), 53incubation of (Murch iso n), 41outbreak of, atNew Barnet (Ratcl ifi e),54

do ., near Cambrid e (Latham), 53do ., near Oxford ayo), 54

peritonitis after, fo llowed by suppura

tion from umb ilicus (Gluge) , 53fever, state of capillaries, &c . , o f in

testine in (Hesch l), 52spread o f, &c . , 482—85

a suppuration in musc les after (KraftE b ing), 53titles o f papers on, 5 5

treatment of (L issauer, Scho lz , Popper,54—55

tuberculosis after (Birch -Hirschfeld),39

w ith fatal paralys is, &c , (Clement), 53Typhus, direct contagion o f (Virchow),5 6

incub ation o f (Murch ison), 41in India (Lyons), 56

Udb c, on trich ino s is , 7 7U lcus serpens corneas , treatment o f

(Pagens techer), 348Ullersperger, case of, th ickening o f skin

of so les o f feet, 850 179U lna, o steo id cancer o f (Bell), 244Ulzmann

, cases o f cystine calculi, 279Underh ill, tracheo tomy 1n croup, &c . , 105Uraem ia from atro ph ied kidney, case of

(Murch iso n), 169tra ns fus ion 1u (Sto hr), 17O

Uraq lasty, 232—33

nasa l muco us memb rane used in

(Lannelo ngue), 334Urates, chem is try of (Barc lay) , 172Urban (D ), amount of oxygen in b loodof different arteries, 13Urea, distributio n o f (Gescheidlen), 19

excretion o f, on (Falck) , 172in liquo r amni i (Gus serow) , 17o n form ation o f, by the kidneys (Roseustein), 19Uretero uterine fis tula, c ases o f, 417Urethra, irritatio n o f the pro sta tic causing o rch itis (Hutch inson), 273stric ture o f the, on (Stokes), 272stric ture o f, o n (Thompso n), 272Urethral fever, fatal , after catheterism'

(Banks), 271Urethro plas ty, cases o f (Wo od, 273Uric ac id, am ount excreted by the kidney(Saw icki), 30

Urinary muco us membrane, tuberculardisease o f (Sm ith), 269umb ilica l fistulaa, o n, 427

Urine, amount of organic m atter in, 172detection o f b iliary ac ids in (Strassburg), 17diagno sis of so urce o f b loo d in, 172experiments on (Wernich), 172—ineonti11ence o f, as a symptom o f retention (Hutch inso n), 273list o f papers on the, 173on sec ret io n of (Ustimowitscb), 19retention o f, case o f, in pre nancy, 399state o f, in leuco cythem ia Salkowski),69

test for sugar in the (Falck) , 172Urticaria, with herpes (Broadbent), 176Ustimowitsch , experiments on secretion

o f urine, 19Uteri, cervix, mechanical dilatatio n of

the (Duncan), 416os , hypertroph ic pro lypus o f the(Barnes), 385

540 INDEX.

Valette, case o f inversion o f the uterus,378Vallin, ease o f pleuritic efl

'

usio n, 113

Valvular d isease (see heart)Vance, o n ep ilepsy, 83Vanilla ice, symptom s o f po ison ing by

(Maurer), 45 2Varicella and sc arlet fever c o inc ident(Bunton,

Musket), 60relation o f, to smallpox (Rommelaere),63

titles o f papers on, 64

Vario la (see smallpox), 67Varix, co ngenital, lymphatic (Paterson),210

treatment o f , by injection o f ergo tin211

Vascular murmurs , on (Nc let), 10Vaudry, o n the use o f ars en ic , 463V anlair, h isto logy o f elephantias is,181

m icro cythem ia , 70on a variety o f fungus, 185

Vedie, rupture o f the heart, 144Vegetab le paras ites , 79Veins , jugular, ulceratio n o f the, o n

(Gro ss), 326V enaesection, effec ts o f, on arterial current (Gatzuck), 9Verga, inoculatio n o f tubercle, 38

V ergely, ca se o f headache w ith increaseo f temperature, 40

Ver neuil , case of rupture o f internal carotid, 84

surgery o f arteries in gunshot wounds,263

suture o f the eyelids, 349on tuberculous tes tis, 281

Verteb ra, !fifth cervica l, disloc ation o f

(Reyburn) , 260Ves ico -vaginal fistula (Bell), 282

case o f doub le, congen ita l, 371Ves sels, conditio n o f the walls o f, in iaflammation (Durante), 33passage o f corpuscles through walls o fthe, 34

Virchow, on chloro s is, 373on direct contag ion of typhus , and on

war typhus ,”5 6

on typhus , 48 5Visual sense, on the, in di sease o f the

choro id and retina (Fo rster, Hippel),364

Vital phenomena , influence of b arometricpres sure on (Bert) , 13Vitrio l, wh ite, po isoning by (Tardieu),Vogt, case of progress ive muscular atro

phy, 71ergotin in treatment of varix, 211 s

Vohl, to xico logical effects of

450

Vo it, tissue changes in pho sph orus

son ing, 441Vo lkm ann, on relative m o rtal ity in

and m ilitary p ractice, 26Vo lvuli , list o f c ases o f, 15Vom iting o f pregnancy , o n the (Hewitt,

400

Vulpian, pustules o f smallpo x, 63

Vulva , hypersesthesia o f the (Mus sy,386

Wade, o n ch loro sis, &c ., 372Wagener, o n structure o fmusc le, 27Wagner, o n tub ercular lymphadenoma,188

Wagstaffe,~

c ase o f fib rous tum our o f the

heart, 138

c ase o f injury to the head, 267lValdenb urg , o n a manometer, 108

Waldeyer, o n diphtheritic puerperalfever, 421o n fibro id o f the o vary, 387

Wallace, diagno sis o f pregnancy, 401Waller, nerves o f deglutitio n, 15

Wal lowiez , o n actio n of alc oh o l, 463Wanklyn, o n c ompo s ition o f urine, 172Ward, medullary sarcoma o f the stom ach ,

153

Wardell, cas e o f exfo liatio n of the femaleb ladder, 400

Waring-Curran, ab scess o f the lung,122

l Varlomont, iridectomy knives , 364rem oval o f suture p ins, 349

Warner, c ase o f ab sence o f the vaginaand uterus, 371

War typhus , on (V irch ow), 5 6Warts, m icroco cc i in (Richter) , 79Water, kinds o f, fo r use, 490Waters o n hay fever, 43

sc irrh ous c ancer o f lung, 124Wa tson, c ase o f rup ture o f the heart,145

Watson (Dr. E ben), calculus in female,278cases o f tracheotomy fo r laryngea ldisease, 321exc is ion of the ankle, 226exc ision o f the astragalus, malleo li,&c ., 226

exc ision o f the elbow fo r anchylo s is,217exe1s ion of extrem ity o f humerus for

anchylo s is, 218exc is ion o f the lower jaw, 228

exc is ion o f wedge of bone at knee,225

Wecker, on corelys is, 348

INDEX ;

Wecker, on extrac tion o f catarac t, 344

Wed], b loo dpath o f th e spleen, 19

c orpusc les in b loo d in syph ilis , 65Wegner, b one disease in hereditary syph i

lis , 307Weigert, b acteria in the skin in smallpox, 63

Weil, on phys io logical action of digitalis,470

Weinb erg , o n treatment of scab ies, 186Weiske, results o f g iving fo od po or inlime o r ph o sph oric ac id, 29Wells (Spencer), d iagno s is of uterine from

ovarian tumours, 381extirpation o f suppurating ovariancysts , 391

o n fever fo llowing surgical operations,317on ovariotomy, 388ovariotomy statis tic s, 301rem oval o f uterine fibro id by abdomi

nal section, 379Wernich , analys is o f the urine, 172

on weigh t of infants, 425West, removal o f naevi with the écraseur,211

Westco tt, case o f rupture o f the heart,145

Westphal, ep ilepsy in guinea-p igs, 82production o f ep ilepsy in guineapigs, 23

Weter, o n pho sphorus p o ison ing, 440Wettengel, delivery o f a dicephalousm onster. 412

Wharton-Ketchum trial, the, 45 6Whipham , case of disease of th e tricusp idvalve, 141Wh ite, cases of inversion of the uterus,417case of po isoning by carb o lic ac id,446

Wh itehead cases o f c left palate,233

cases o f stricture of the rectum , 299

on membranous enteritis, 15 6pecul iar sputa, 109

Wh itney, c ase o f emphysema duringlab our, 418Who op ing-cough, on (Steffen, McCall),117titles of papers o n, 118

Widerh ofer, on rickets, 429tetanus neonatorum , 428

W ilde, on traumatic erys ipelas, 318Wilks, on adherent pericardium , 136

case o f haematidro s is, 183W illiam s, on phth is is , 127W illy, on exc itation o f nerves, 21

Wilson cases o f prurigo , 178

541

Xanthelasma palpebrarum (Hutch inson);183

Y arrow, case o f Caesarean sectio n, 413Y eld, case o f fibrous tum o ur rem oved

a fter lab our, 419Y ellow fever, o n, 45—47titles of papers on, 47

Zahn, on detectio n of b lo od-stains , 459Zallonis, ino culab ility of tubercle, 38

Wilson (E ). case of erythema so lare, 174W ilson (J . c ase o f erup tion after

applicatio n o f b elladonna, 423W iltsh ire, case o f rupture o f the heart,145

fatal tetanus after abortion, 403on the c o lour of the eyes o f the newlyb orn, 426

V Vinan ts, on case of transfusion, 330Winckel, cases of sarcoma o f the uterus,377vag inal cysts, 385

W ire, removal of, after operation for

unun ited fracture, 2 56W oh lrab , on typh o id, 483Wo inow, astigmatism after cataract operations; 347diagno s is of co lour b lindness , 340

Wo lferz, innervation o f lachrymal glands,2 5

Wo lffbey, tens ion o f carb onic ac id inlungs and b lo od, 15

Wo o d (Pro f. H. effects o f atrop ineon pup ils of p igeons, 449o n n itrite o f amyl, 466

Wo od (Mr. J an improved gag, 233on urethrop lasty, 273leuco cythem ia, 69on neph ritis, 167use o f brom ides , 462

Wo odward, case o f invers ion o f theuterus, 418

Wounds , dress ing o f (Callender), 198on open treatm ent of (Krtinlein),195

Wrany, emb o lism, &c ., after endo car~

ditis, 134

Wright, a new self-reta ining catheter,271m eth od o f b isecting foetus , 414

Wrist, dislo cation of (E richsen , Adams),248

dro p , from injury to nerve in frac ture(E rich sen), 256exc is io n o f, cases of, 218

Wyss, extravasations in smallpox, 63011 herpes zo ster, 175

542 m ax.

LZehnder, repo rt'

on“

cho lera epidem ic , Z immer, on diabetes, 72Z inc , sulphate o f, o n po isoning by (TarZeis chei10plastic operation , 330 d ieu), 443Zenker, o n trich ino s is , 78 Zub er, case o f hydatids in lung, 79,Z illmer, cases of co l lo id cysts , 188 125

Z imm . case o f po isoning by carb o lic ac id, Zuntz, on po iso ning by carbom c oxide,

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